^ll>    ii\! 


M'.-ii 


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http://www.archive.org/details/diseasesofthroatOOcohe 


In  Preparation 

BY    THE     AUTHOR     OF    THIS    V0LU3HE: 

DEFECTS  OF  VOICE  AND  SPEECH: 

PRECEDED  BY  A  PHYSICO-PHYSIOLOGICAIi  ESSAY  ON 

THE  FORMATION  OF  THE  VOICE;  AND  THE  MECHANISM 

OF  SPEECH. 

ILLUSTRATED. 


DISEASES  OF  THE  TMOAT: 


A    G-XJIDE    TO    THE 


DIAG^^OSIS  AND  TREATMENT  OF  AFFECTIONS 


PHAEYNX,  (ESOPHAGUS,  TRACHEA, 
LARYNX,  AND  NARES. 

By   J.   SOLIS   COHEN,  M.D., 

LECTUEEE     ON    LARYNGOSCOPY   AND  DISEASES   OF   THE    THROAT   AND  CHEST,    IN 
JEFFERSON   MEDICAL   COLLEGE,    PHILADELPHIA. 

MUTTER     LECTURER     BEFORE    THE     COLLEGE     OF     PHYSICIANS,     PHILADELPHIA  ;     PERMANENT 
MEMBER     OF     THE     AMERICAN     MEDICAL     ASSOCIATION  ;      AND     OF     THE     MEDICAL 
SOCIETY     OF    THE    STATE    OF    PENNSYLVANIA.      FELLOW    OF   THE    COL- 
LEGE OF  PHYSICIANS,  PHILADELPHIA  ;    ACTIYE,  HONORARY, 
AND    CORRESPONDING    MEMBER   OF   VARIOUS    MEDI- 
CAL, SCIENTIFIC,  AND  LITERARY   SOCIETIES  ; 

LATE   ACTING   ASSISTANT-SURGEON   IN   THE   NAVY  OF  THE   UNITED  STATES,    ETC.,    ETC., 

WITH  133   ILLUSTRATIONS  ON  WOOD. 


NEW    YORK: 
WILLIAM  WOOD    &   COMPANY. 

1872. 


Entered  according  to  Act  of  Congress,  in  the  year  1872, 

By  "WILLIAM  WOOD  h  CO., 

In  the  Office  of  the  Librarian  of  Congress,  at  Washington,  D.  C. 


Poole  &  MACLAtrcHiAN,  Printebs, 

2U5-2i;^  East  Tioelfth  St. 

New  Yoek. 


LOUIS  ELSBERG,  M.D., 


Clinical   Professor   of  Diseases   of  the   Throat   in   the  University  of  New  York 
and  the  most  accomplished  Laryngoscopist  in  America  : 


MY    SCHOOLMATE    IN    BOYHOOD,    MY    FELLOW-STUDENT     IN    MEDICINE, 
MY    CO-LABOKER    AND    OFTEN    MY    GUIDE 

IN 

THOSE    DEPARTilENTS    OP    PKOPESSIONAL    AND    GENER.\L   SCIENCE   TO  WHICH 

AVE    ABB    BOTH    DEVOTED, 

AND    EVER    MY    GENEROUS    AND    WARM-HEARTED    FRIEND: 

(Ellis  i3D0vk  is  ^f  cctionatels  Inscribed, 

IN  RECOGNITION  OP  HIS   PROFESSIONAL   TALENTS ;    HIS  SCHOLASTIC  ACQUIRE  • 
MENTS;   HIS   SOCIAL   VIRTUES;    AND   HIS  MANLINESS. 


^I)e  ^xttlior. 


PREFACE. 


The  jireparation  of  the  following  pages  lias  been  no  holiday  task 
on  the  part  of  the  author.  Only  such  irregnilar  intervals  as  could  be 
snatched  from  the  requirements  of  an  unusually  arduous  practice 
could  be  devoted  to  the  purpose.  Hence  there  has  ensued  an  in- 
equality in  composition  of  which  the  writer  is  sensibly  cognizant. 
Some  subjects  have  had  to  be  discussed  in  a  manner  rather  different 
from  that  originally  contemplated,  and  the  context  of  numerous  refer- 
ences, toilsomely  collected  for  their  elucidation,  has  remained  unin- 
corporated. 

With  the  exception  of  a  few  hospital  and  dispensary  patients,  seen 
from  time  to  time  at  the  request  of  his  professional  friends,  the 
author's  entire  experience  has  been  confined  to  his  own  private  and 
consultation  practice.  This  has  debarred  him  from  much  opportunity 
for  personal  pathological  research  ;  but  it  has  facilitated  the  descrip- 
tion of  morbid  processes  as  they  are  met  with  in  the  oixlinary  routine 
of  practice,  a  matter  of  no  slight  recommendation  to  the  general  pro- 
fessional reader,  and  one  which  it  is  hoped  will  compensate,  at  least 
in  part,  for  deficiencies  in  other  directions. 

The  limits  of  a  moderate-sized  volume  preclude  the  composition  of 
an  exhaustive  treatise  on  the  subject  of  Diseases  of  the  Throat. 
It  has  been  thought  advisable,  therefore,  while  presenting  a  compre- 
hensive view  of  the  entire  field,  to  dwell  longer  upon  subjects  which 
are  important  by  their  frequency  and  by  the  fresh  light  shed  upon 
them  by  recent  investigation  ;  and  to  treat  concisely  of  those  points 
which  by  their  infrequency  on  the  one  hand,  or  their  thorough  discus- 
sion in  the  standard  medical  works  of  the  day  on  the  other,  seem  less 
to  call  for  amplification. 

It  is  impossible  to  furnish  an  explicit  and  perfect  description  of  a 
disease  so  as  to  afford  a  complete  and  satisfactory  mental  picture  of 
the  condition  of  every  example  of  it  which  may  come  under  notice. 
Each  case  exhibits  some  special  phenomena  of  severity  or  of  mildness ; 
or  is  different  in  some  other  particular  from  every  other  case  with  the 


Vlll  PEEFACE. 

same  general  aspect.  All  that  a  writer  can  do  is  to  mention  the 
characteristics  which  determine  the  nature  of  the  diseased  action 
going  on,  to  designate  the  elements  of  danger  and  of  safety,  and  to 
indicate  the  methods  of  management  which  reason  and  experience 
have  proven  to  be  most  adequate  for  relief,  or  best  productive  of  cure. 
In  attempting  this,  much  has  to  be  said  which  others  have  said 
already,  and  often  in  better  language ;  but  this  repetition  is  sometimes 
necessary  to  complete  the  outline  of  a  subject,  or  to  convey  intelli- 
gence for  the  first  time  to  those  who  have  not  had  access  to  original 
sources  of  information. 

Due  consideration  has  been  given,  in  the  siibject  matter  of  the 
volume,  to  modern  developments  in  the  diagnosis  and  treatment  of 
affections  of  the  throat,  especially  those  occupying  the  trachea,  larynx, 
upjier  pharynx,  and  nasal  passages.  Here  the  author's  experience 
has  been  ample ;  and  if  his  record  differs  in  some  respects  from  the 
records  of  others,  it  does  so  by  reason  of  an  honest  endeavor  to  inter- 
j)ret  facts  and  observations  as  they  appeared  in  the  light  of  his  o^ti 
understanding.  The  articles  on  laryngoscopy,  rhinoscopy,  and  surgical 
manipulations  by  their  aid,  are,  with  some  additions,  modifications, 
and  omissions,  essentially  reprints  of  those  contributed  by  the  author, 
a  few  years  ago,  to  the  columns  of  The  Medical  Record,  of  Xew 
York,  and  to  the  second  American  edition  of  Mackexzie  on  the 
Use  of  the  Lauykgoscope. 

The  author  has  availed  himself  of  the  labors  of  his  predecessors 
and  contemporaries,  in  the  production  of  this  volume,  as  freely  as 
he  has  resorted  to  them  for  his  own  instruction.  He  has  endeavored, 
except  in  so  far  as  certain  general  matters  have  long  become  the 
common  property  of  the  profession,  to  give  due  credit  to  his  sources 
of  information. 

For  the  use  of  the  studious  and  the  curious,  he  has  appended  a 
bibliographical  record,  culled  from  his  own  index-rerum  ;  and  this 
has  been  distributed  under  catch-heads,  as  being  more  convenient 
for  consultation  than  a  purely  alphabetical  list  of  authors,  or  a  mere 
chronological  arrangement. 

Acknowledgment  is  made  to  Mr.  G.  H.  Gemrig,  of  Philadelphia, 
for  many  illustrations  of  surgical  instruments  ;  and  also  to  Messrs. 
Otto  &  Reynders,  and  to  Messrs.  Tiemann  &  Co.,  of  New  York,  for 
like  favors.  All  the  original  woodcuts  in  the  volume,  and  many  of 
the  copied  ones,  were  engraved  by  Mr.  Sebald,  of  Philadelphia. 

1327  Geeen  Street,  PHtLADELPHiA,  May,  1872. 


TABLE  OF  CONTENTS. 


CHAPTER  I. 

PAGE 

DISEASES  OF  THE  THROAT  IN  GENERAL 1 


CHAPTER  II. 

EXAMINATION  OF  THE  THROAT. 
Oedikaky  inspection. — Lakyngoscopt. — Auto  -  laeykgoscopy. 

— DeMONSTRO  -  LARYNGOSCOPY. — InFRA-GLOTTIC  LARYN- 
GOSCOPY. —  CESOPHAGOSCOPY.  —  REGIONAL  ANATOMY  OF 
THE  LARYNX. — EXAMINATION  OF  THE  LARYNGEAL  IMAGE 
IN  DETAIL. — The  MUSCULAR  FORCES  PRODUCING  CHANGES 

in  the  -form  of  the  glottis. — mucous  membrane, 
glands,  blood-vessels,  and  nerves  op  the  larynx. — 
Histology  of  the  larynx.— Rhinoscopy 6 

CHAPTER  III. 

SORE  THROAT. 
Erythematous    sore-throat.  —  Phlegmonous    sore-throat. — 

Ulcerated  sore-throat. — ]\Iembranous  sore-throat.  78 

CHAPTER  lY. 
DIPHTHERIA 97 

CHAPTER  Y. 

THE  SORE-THROATS  OF  TPIE  EXANTHEMATA. 

The  Sore-throat  op  Small-pox. — The  Sore-throat  of  Mea- 
sles.— The  Sore-throat  of  Scarlatina. — Erysipe- 
latous  Sore-throat '. 104 


X  TABLE    OF   COIS^TEXTS. 

CHAPTEE  YI. 

SYPHILITIC  SORE-THROAT. 

PAGE 

Syphilitic   Soke-theoat  of  adults. — Syphilitic   Sore-thoat 

of  infants ' 113 

CHAPTEE  YII. 
SORE-THROAT  FROM  BLT^NS  AND  SCALDS 123 

CHAPTEE  YIII. 

SPECIAL  AFFECTIONS  OF  THE  TONSILS. 
Foreign   bodies. — Calcareous  concretions. — Cancerous   tu- 
mors.— Cystic  tumors. — Permanent  enlargement  of 
the  tonsils 125 

CHAPTEE  IX. 

SPECIAL  AFFECTIONS   OF  THE   PALATE   AND  UYULA, 
The  pharyngo-palatine  muscles. — Tumors  of  the  palate. — 
Cleft-palate.— Paralysis  of  the  palate, — Chronic 

elongation   of   the  UTULA.  —  CEcEilA  OF  THE  UVULA. — 

Excrescences  on  the  uvula. — Bifid  uvula 133 

CHAPTEE  X. 

SPECIAL  AFFECTIONS  OF  THE  PHARYNX. 
Abscess  of  the  pharynx. — Chronic  follicular  pharyngitis. 
— Glandular  hypertrophy  at  the  vault  of  the 
pharynx. — Tumors  of  the  pharynx. — Pharyngocele. 
— Naso-pharyngeal  tumors. — Wounds  of  the  pha- 
rynx   148 

CHAPTEE  XI. 

SPECIAL   AFFECTIONS  OF  THE  (ESOPHAGUS. 
(Esophagitis. — Congenital   occlusion   op  the   cesophagus. — 
Congenital  fistulk  of  the  (esophagus. — Stricture 


TABLE    OF    COIS^TEISTTS.  XI 

PAGE 

OF  THE  cEsornAGUs. — Spasm  op  the  cesophagus. — Dila- 
tation OF  the  cesophagus. — Glosso-pharykgeal  paka- 
TiYsis. — Tumors  ik  the  cesophagus. — "Wounds  op  the 
CESOPHAGUS. — Foreign  bodies  in  the  oesophagus. — 
Fancied  bodies  in  the  pharynx  and  cesophagus. — 
CEsophagotomy 212 

CHAPTER  XII. 

AFFECTIONS  OF  THE  NASAL  PASSAGES. 
The  nasax,  jiucous  iiembrane. — Epistaxis. — Nasal  abscess. — 
CoRYZA. — Idiosyncratic  coryza. — Influenza. — Chro- 
nic CORYZA. — Oz^na. — The  nasal  douche. — Anosmia. 
— Syphilitic  affections  of  the  nasal  passages. — 
Paralysis  of  the  nostrils. — Occlusion  op  the  nos- 
trils.— Congenital  occlusion  of  the  posterior  nares. 
— Inflamjviation  op  the  nasal  septum. — Submucous 
infiltration  at  the  sides  of  the  vomer. — Tumors  op 
THE  septum. — Deviations  op  the  septum  from  the 

AODDLE  LINE. — FoREIGN  BODIES  IN  THE  NOSTRILS.- — CAL- 
CAREOUS ACCRETIONS  IN  THE  NASAL  POSS^. — TUJIORS  IN 
THE     NASAL     PASSAGES. — TAMPONING    THE     POST-NASAL 

Foss^ 243 

CHAPTER  XIII. 

AFFECTIONS  OF  THE  FRONTAL   SINUS. 
Inflammation. — Abscess. — Tumors 325 

CHAPTER  XIY. 

AFFECTIONS  OF  THE  LARYNX  AND  TRACHEA. 
Acute  laryngitis. — Oedema  of  the  larynx. — Chronic  Laryn- 
gitis.— The    chronic    laryngitis   of  phthisis. — The 
chronic    laryngitis    of    syphilis.  —  manipulations 

."WITHIN  THE  LARYNX. —  ElEPHANTL^SIS  OP  THE  LARYNX. 

— ^Inflammations  of  the  trachea. — Constriction  op 

THE  trachea. — FiSTULE  OF  THE  LARYNX  AND  TRACHEA. 


Xll  TABLE    OF    COISTTEISTTS. 

PAGE 

— Croup. — Growths  in  the  larynx. — Tumors  of  the 
TRACHEA. — Foreign  bodies  in  the  larynx  and  tra- 
chea.— Aphonia. — Laryngis^ius  stridulus. — Spasmo- 
dic cough.— Whooping-cough. — Wounds  op  the  la- 
rynx   AND    TRACHEA. — FRACTURES    OF    THE    LARYNX. — 

Fractures  of  the  trachea. — Rupture  of  the  tra- 
chea.— Contusions  op  the  larynx  and  trachea. — 
Artificial  openings  into  the  larynx  and  trachea. — 
Catheterization  of  the  larynx  and  trachea. — Af- 
fections of  the  laryngo-pharyngeal  sinus 333 

CHAPTEE  XV. 

DISEASES   OF  THE  NECK  AFFECTING  THE  DEEPER  TISSUES 
OF  THE  THROAT  SECONDARILY. 
Diffuse  inflamjiation  of  the   Connective  tissues  of  the 
NECK. — Tumors  of  the  neck. — Mumps.^ — Bursal  tumors 
op  the  thyro-hyoid  region. — Affections  op  the  thy- 
roid gland. — Affections  of  the  thymus  gland^ 507 

REFERENCES  ON  SUBJECTS  TREATED  OF  IN  THE  TEXT. .         ,533 

INDEX ; 573 


LIST  OF  ILLUSTRATIONS. 


FIG.  PAGE 

1.  Tong-ue-cTepressors 7 

2.  Tobold's  tongue-depressor 8 

8.  Tiirck's  tongue-depressor 8 

4.  Hard-rubber  tongue-depressor 9 

5.  Laryngoscopic  mirror  of  circular  form 13 

6.  Side  and  front  views  of  laryngoscopic  mirrors  of  different  forms 

and  sizes  (Tobold) 14 

7.  The  laryngoscopic  mirror  in  position 17 

8.  Manner  of  holding  laryngoscopic   mirror  prcAdous  to  its  intro- 

duction      18 

9.  Relative  relations  of  larynx  and  its  image  in  the  laryngoscopic 

mirror 19 

10.  Von  Brun's  pincette  for  holding  up  the  epiglottis 26 

11.  Examination   by    reflected    light,    with  reflector    on    forehead 

(from  Beunet) 29 

12.  Tobold's  apparatus  for  artificial  illumination  (Toboldj 31 

13.  Tobold's  apparatus  for  illumination,  with  stand  (Tobold) 33 

14.  Tobold's  illuminating  apparatus,  fed  with  gas,  supported  from 

floor,  with  arm  of  reflector  above  the  lenses;  the  whole 
movable  up  or  down,  right  or  left,  by  means  of  a  supporting 
rod,  sliding  in  the  socket  of  the  stand 34 

15.  Examination  of  the  larynx  by  means  of  Tobold's  packet  illumi- 

nator (Tobold) 35 

16.  Czermak's  auto-laryngoscopic  apparatus  (Czermak) 38 

17.  Tobold's  perforated  canula,  and  small  metallic  mirror  for  infra- 

glottic  laryngoscopy 44 

18.  Normal  larynx  during  inspiration 54 

19.  Laryngoscopic  clramng,  showing  the  vocal  cords  drawn  widely 

apart,  and  the  position  of  the  various  parts  above  and  below 
the  glottis,  during  quiet  inspiration  (Mackenzie) 58 

20.  Laryngoscopic  drawing,  showing  the  approximation  of  the  vocal 

cords,  and  the  position  of  the  various  parts  in  the  act  of 

vocalization  (Mackenzie) 58 

21.  Rhinoscopic  image 72 

22.  Rhinoscopic  image  in  a  case  of  cleft  palate 73 

23.  Case  of  cleft  palate  affording  image  of  Fig.  22 73 

24.  Rhinoscopic  view  of  left  Eustachian  orifice 74 

.  25.  Elsberg's  nostril  dilator  and  speculum '. 76 

26.  Thudichum's  dilating  speculum  for  the  nostrils 76 


XIV  LIST    OF   ILLUSTRATIONS. 

FIG.  PAGE 

27.  Syphilitic  ravages   in  the  soft  palate,  tonsil,  and  lateral  pha- 

ryngeal wall 117 

28.  Syphilitic  ravages  ia  epiglottis,  and  lateral  laryngeal  wall,  in 

same  case  as  Fig.  37 11"? 

29.  Fahnestock's  tonsillotome 129 

30.  Physick's  tonsillotome    129 

31.  Charri^re's  tonsillotome 130 

32.  Anterior  view  of  the  musculature  of  the  pharynx  and  palate, 

after  removal  of  tongue,  hyoid  bone,  and  larynx,  as  far  as 

the  posterior  segment  of  its  thyroid  cartilage  (Luschka) 136 

33.  Mouth-distender  for  facilitating  the  operation  for  cleft  palate, 

and  other  operations  within  the  mouth  (Whitehead) 142 

34.  Mouth-distender   in  position  for  the  operation  of  cleft  palate 

(Whitehead) 142 

35.  Follicular  pharyngitis 161 

36.  Chronic  follicular  j)haryngitis 163 

37.  Adenoid  tissue  of  vault  of  pharynx  (Luschka) 178 

38.  Pharyngeal  bursa  (Luschka) 181 

39.  View  of  glandular  tissue  at  vault  of  pharynx,  in  a  case  of  cleft 

palate 185 

40.  View  of  Eustachian  orifice  in  a  case  of  cleft  palate 186 

41.  Rhinoscopic  view  of  glandular  vegetations  at  vault  of  pharynx.  190 

42.  Rhinoscopic  view  of  a  case  of  glandular  hypertrophy  at  vault  of 

pliarynx 193 

43.  (Esophageal  dilators  for  stricture 219 

44.  Enormous  dilatation  of  oesophagus  (Luschka) 223 

45.  Bond's  oesophageal  forceps 235 

46.  Burge's  oesophageal  forceps 235 

47.  Horsehair  snare  and  probang  for  the  removal  of  foreign  bodies 

from  the  oesophagus 236 

48.  Canula  of  Bellocq  for  plugging  posterior  nares 250 

49.  Buttle's  nasal  inhaler 258 

50.  Lewin's   arrangement  for   generating  nascent   muriate   of    am- 

monia    276 

51.  Thudi chum's  nasal  douche  (Thudichura) 279 

52.  Nasal  douche 287 

53.  Thudichum's  syphon  nasal  douche 287 

54.  Syphon  douche  with  compression-bulb 288 

55.  Manner  of  arranging  syphon  nasal  douche 288 

56.  Rhinoscopic  image  of  oedema  of  nasal  septum 299 

57.  Rhinoscopic  image  of  oedema  of  nasal  septum 299 

58.  Submucous  infiltration  of  posterior  nasal  septum  supposed  to  be 

due  to  mycelium 299 


LIST    OF    ILLUSTRATIONS.  XV 

FIG.  PAGE 

59.  Gross'  instrunaents  for  removal  of  foreign  bodies  from  the  nose.  .  304 

60.  Gelatinoid  nasal  poly^D  (Liston) 308 

61.  Polypus  forceps 312 

62.  Buck's  knife  for  scarifying  an  osdematous  larynx 343 

63.  Laryngoscopic  appearance  of  oedema  of  larynx  with  ulceration, 

in  the  latter  stage  of  phthisis 361 

64.  Mounted  skull  for   preliminary  practice  in  the  operative  pro- 

cedures of  intra-laryngeal  surgery  (Tobold) 381 

65.  Laryngeal  brush  and  sponge-holder 386 

66.  Tiirck's  laryngeal  brush 387 

67.  Tol)old's  laryngeal  syringe 387 

68.  Gibb's  laryngeal  douche 387 

69.  Newman's  spray-producer 388 

70.  Rauchf uss'  laryngeal  powder-insufflator 389 

71.  Tumors  on  both  vocal  cords,  producing  sudden  death 409 

72.  Tumor  on  left  vocal  cord,  producing  sudden  death 409 

73.  Tobold's  sponge-holder  (Tobold) 421 

74.  Sponge-holder 421 

75.  Elsberg's  sponge-holder 422 

76.  Toljold's  forceps  for  nitrate  of  silver  in  stick  (Tobold) 422 

77.  Tobold's  roughened  probe  for  the  use  of  molten  nitrate  of  silver 

(Tobold) 422 

78.  Tobold's  concealed  holder  for  molten  nitrate  of  silver,  or  for 

chromic  acid  (Tobold) 423 

79.  Excrescence  on  left  vocal  cord 424 

80.  Excrescence  on  right  vocal  cord . ' 424 

81.  Epithelial  growths  on  both  vocal  cords,  in  a  case  of  phthisis. . .  .  425 

82.  Appearance  of  cords  after  destruction  of  growths  with  chromic 

acid 425 

83.  Tobold's  laryngeal  forceps  (Tobold) 428 

84.  Fauvel's  laryngeal  forceps 428 

85.  Cuzco's  laryngeal  forceps 429 

86.  Mackenzie's  laryngeal  forceps  (Mackenzie) 430 

87.  Tobold's  concealed  pincette  (Tobold) 431 

88.  Mackenzie's  lai'yngeal  tube-forceps  and  scissors  (Mackenzie) ....  432 

89.  Papillary  gro^vths  in  phthisis,  removed  with  forceps 433 

90.  Papilloma  occupying  posterior  laryngeal  wall,  and  removed  by 

evulsion 433 

91.  Pedunculated  polyp  on  vocal  cord,  in  a  case  of  phthisis 433 

92.  Pedunculated  fibroid  polyp  beneath  vocal  cords,  and  removed  with 

Fauvel's  forceps 433 

93.  Laryngeal  growths  renioved  by  evulsion  and  caustics 434 

-94.  Same  case  as  Fig.  93,  after  removal  of  growths 434 


XVI  LIST    OF   ILLUSTEATIOlSrS. 

FIG.  PAGE 

95.  Tobold's  concealed  knife  (Tobold) 436 

96.  Tobold's  lancet-pointed  probe  (Tobold) 436 

97.  Tobold's  knife,  with  double  cutting  edge  (Tobold) 437 

98.  Tobold's  knife,  with  single  cutting  edge  (Tobold) 437 

99.  Tobold's  perpendicularly  cutting  scissors  (Tobold) 438 

100.  Tobold's  horizontally  cutting  scissors  (Tobold) 438 

101.  Gibb's  wire-snare  for  larynx  (Gibb) 439 

102.  Tobold's  wire-snare  for  laryngeal  groT^'ths  (Tobold) 439 

103.  Guarded  wheel  ecraseur  (Mackenzie) 441 

104.  Tobold's  chain-ecraseur  (Tobold) : .  441 

105.  Voltolini's  laryngeal  galvano-cautery 442 

106.  A  simple  form  of  galvano-cautery  for  the  larynx 442 

107-112.  Burners  and  cutting  loops  for  galvano-cautery  (Bruns) 443 

113.  Pimple  on  the  epiglottis,  removed  by  galvano-cautery 444 

114.  Fibrous  tumor  on  right  vocal  cord,  removed  after  thyi-otomy, 

without  tracheotomy 445 

115.  Laryngeal  growths,  for  the  removal  of  which  thyrotomy  was  per- 

formed after  tracheotomy 446 

116.  Appearance  of  the  parts  some  months  after  operation 446 

117.  Appearance  of  the  parts  some  years  after  the  operation 446 

118.  Dr.  Schrotter's  case  of  tumor  of  the  trachea  (Schrotter) 452 

119.  Paralysis  of  left  vocal  cord  in  a  case  of  phthisis.     Appearance 

clm'ing  respiration 465 

120.  Paralysis  of  left  vocal  cord  in  a  case  of  phthisis.     Appearance 

dming  attempt  at  phonation 465 

121.  Paralysis  of  left  vocal  cord  in  a  case  of  aneurism  of  the  aorta. 

Appearance  during  respiration 466 

122.  Paralysis  of  left  vocal  cord  in  a  case  of  aneurism  of  the  aorta. 

Appearance  during  attempted  phonation 466 

123.  Aphonia,  with  momentary  normal  closure  of  glottis.     Also  repre- 

sents aphonia  Avitli  normal  closure,  but  want  of  vibration  of 

one  or  both  cords  (Tobold)   467 

134.  Complete  paralysis  of  both  cords  (Tobold) 467 

125.  Paralysis  of  thyro-arytenoid  muscles.     Closure  of  the  iuter-ary- 

tenoidal  space  of  the  glottis,  that  portion  between  the  A'^ocal 

cords  remaining  open  (Tobold) 467 

126.  Elliptical  opening  of  entire  glottis  (Toljold) 468 

127.  Want  of  approximation  of  the  arytenoid  cartilages 468 

128.  Mackenzie's  laryngeal  electrodes 471 

129.  Trousseau's  double  tracheotomy  tube 498 

130.  131.  Howard's  extemporaneous  tracheotomy  tube  (Howard) 499. 

132.  Trousseau's  dilator  for  use  in  tracheotomy -503 

133.  Hewson's  torsion  forceps 511 


DISEASES  OF  THE  THROAT. 


CHAPTER    I. 

DISEASES    OF   THE    THEOAT   IIT    GEJ^TERAL. 

The  diseases  of  tlie  throat  met  with  in  the  practice  of  medicine 
do  not  differ  materially  from  the  diseases  encountered  in  other 
regions  of  the  body.  Inflammation  occurs  in  its  various  grades  ; 
and  this  may  be  idiopathic  or  traumatic  ;  or  it  may  exist  as  an 
integral  element,  or  as  a  result,  of  systemic  affections,  such  as 
tubercle,  syphilis,  scrofula,  cancer,  rheumatism,  gout,  erysipelas 
and  the  exanthemata,  albuminuria,  aneurism,  the  chronic  affec- 
tions of  the  skin,  etc. 

Then  we  have  the  products  of  inflammation,  glandular  swell- 
ings, tumors  benign  and  malignant,  strictures,  etc. ;  and,  finally, 
we  encounter  various  nervous  affections  of  the  throat. 

The  mucous  membrane  of  the  throat  is  exceedingly  prone 
to, disease,  partly  from  its  exposed  condition,  partly  from  a 
peculiar  proclivity,  the  nature  of  which  is  but  imperfectly 
understood,  and  partly  from  extension  of  disease  existing  in 
adjacent  parts,  not  infrequently  the  skin,  with  the  affections  of 
which  it  has  much  in  common,  in  consequence  of  analogy  of 
construction. 

The  treatment  of  diseases  of  the  throat  is  rendered  more  ]3ro- 
tracted  than  the  treatment  of  diseases  in  most  other  portions 
of  the  body,  on  account  of  the  difficulty  of  protecting  the 
affected  structures  from  the  contact  of  the  air,  and  the  im- 
practicability of  keeping  up  local  applications  with  any  degree 
-of  continuousness ;  a  circumstance  which  compels  a  course  of 
management  differing  from  that  which  would  be  employed  in 


2  DISEASES    OF   THE    THEOAT   IJST    GENERAL. 

similar  affections  occiirring  elsewhere,  where  we  avail  ourselves 
of  the  plaster  and  the  compress,  with  or  without  resort  to  the 
use  of  remedial  agents. 

In  almost  all  diseases  of  the  throat,  the  secretion  fi-om  the 
mucous  membrane  is  affected.  Sometimes  it  is  simply  dimin- 
ished in  quantity,  sometimes  it  is  simply  increased  in  quantity  ; 
but  most  frequently  it  is  altered  in  quality  as  well  as  in  quantity. 
The  normal  secretion  of  the  mucous  membrane  is  seen  to  be  a 
transparent  watery  exhalation,  equably  diffused  over  the  surface, 
and  gi^^ng  little  or  no  refractive  evidence  of  its  existence.  It 
serves  to  keep  the  j)aii;s  moist,  pliable,  and  in  a  state  of  comfort ; 
and  it  protects  them  from  the  irritating  influence  of  external 
matters,  whether  present  in  the  air,  or  brought  in  contact  under 
special  circumstances  of  employment  or  exposure. 

The  most  common  effect  of  simple  irritation  of  the  mucous 
membrane  is  the  collection  of  this  exhalation  into  drops,  which 
present,  according  to  the  direction  of  light  under  which  they  are 
examined,  the  aj)pearance  of  minute  vesicles  or  granules ;  and 
although  this  is  not  an  evidence  of  active  or  serious  disease, 
throats  exhibiting  this  appearance  are  often  called  granular,  not 
in  the  mere  sense  of  description,  but  with  the  idea  that  the 
mucous  membrane  is  deprived  of  its  epithelial  coat,  and  that  the 
globules  or  granules  are  the  prominences  of  enlarged  follicles  or 
muciparous  glands — a  condition  which  sometimes  exists  under 
circumstances  to  be  mentioned  in  the  sequel.  Under  this  misap- 
prehension many  an  unoffending  throat  has  been  unhesitatingly 
cauterized  and  re-cauterized,  and  therefore  heedlessly  subjected 
to  the  chance  of  sustaining  permanent  injury ;  a  result,  however, 
which  fortunately  does  not  always  follow  in  this  class  of  affections, 
inasmuch  as  reparation  is  prompt,  owing  to  the  good  state  of  the 
general  health,  and  the  innocuousness  of  the  agent  most  frequent- 
ly applied  upon  the  healthy  mucous  membrane.  Sometimes,  in- 
deed, it  must  be  acknowledged  that  such  treatment,  if  not  repeat- 
ed frequently,  as  is  too  often  the  case,  seems  to  rouse  up  the  latent 
vascular  action  of  the  part,  and  conduce  to  prompt  resumption 
of  function. 

The  researches  of  physiologists  teach  us  that  healthy  mucous 
membrane  does  not  secrete  mucus,  proj)erly  so  called. 


DISEASES    OF   THE    THKOAT   IN    GENERAL.  3 

When  mucous  membrane  is  diseased,  the  new  nuclei,  which 
would  otherwise  have  been  formed  into  epithelial  cells,  take  on 
the  active  cell-growth  of  a  lowered  organization,  and  adhere  to 
each  other  in  masses  which,  with  the  fluids  in  which  they  are 
held,  are  known  to  us  as  mucus.  This  increased  cell-action  is 
very  great,  often  producing  material  in  much  greater  abundance 
than  could  be  furnished  by  the  extent  of  mucous  surface  involved, 
were  the  entire  mass  of  mucus  a  mere  secretion  from  that  sur- 
face. Physiologists  account  for  the  copious  collections  of  mucus 
sometimes  encountered  on  mucous  membranes,  by  the  growth  of 
the  nuclei  and  their  offspring,  after  their  deposition  upon  the 
surface  of  the  membrane  as  well  as  while  in  its  interior. 

"When  the  epithelium  of  a  mucous  membrane  is  absent,  a 
supei-ficial  excavation  is  noticed,  a  mere  erosion  or  abrasion, 
which  is  often  mistaken  for  an  ulceration  invohdng  the  proper 
tissue  of  the  membrane  itself.  The  unevenness  observed  upon  the 
surface  of  the  mucous  membrane  in  the  inflammatory  condition 
is  due  to  the  rapid  and  unequal  proliferation  of  immature  epi- 
thelium cells,  which,  transforming  into  mucus,  are  making  their 
way  through  the  membrane  to  the  surface,  pushing  it  outwards 
from  behind,  as  it  were  ;  and  as  this  action  continues  in  the  local- 
ities in  which  it  first  set  up,  the  enlargement  becomes  a  more  or 
less  permanent  one,  until  the  action  is  changed  by  treatment  or 
otherwise.  There  is  by  no  means  a  necessary  destruction  of  the 
superficial  epithelium  of  mucous  membranes  secreting  mucus, 
as  met  with  even  in  severe  catarrhal  inflammations,  and  though 
they  may  be  purulent  in  character.  In  fact,  experience  would 
go  to  show  that  this  condition  is  excej)tional,  antecedent  to  such 
cases  only  as  evince  a  disposition  to  ulceration  from  their  com- 
mencement, whether  arising  fi'om  diathesis,  violence  of  action, 
or  want  of  proper  attention  at  an  early  period  of  the  disease. 

In  addition  to  the  mucus  found  upon  the  surface  of  diseased 
mucous  membrane,  we  sometimes  discover  fibrin  in  the  secre- 
tion, small  quantities  of  it  having  coagulated  spontaneously  into 
clots  or  flocculi. 

In  some  forms  of  inflammation  of  the  mucous  membrane 
there  is  poured  out  in  abundance  an  albuminoid  secretion,  which, 
under  certain  conditions,  becomes  concreted  into  a  thin  pellicle 


4  DISEASES    OF   THE    TUKOAT   IIST    GENERAL. 

or  membrane,  either  from  coagulation  of  the  fibrin  which  it 
contains,  or  from  evaporation  of  the  watery  constituents  present 
at  the  period  of  exudation. 

Most  of  the  inflammatory  affections  of  the  throat  commence 
in  the  pharynx,  or  pharynx  and  mouth ;  though  not  infrequently 
they  begin  in  the  nasal  passages.  Sometimes  the  initial  disturb- 
ance takes  place  in  the  larynx,  or  even  in  the  trachea  or  bronchi. 
Although  the  pharynx  is  directly  continuous  with  the  03sopha- 
gus,  the  extension  of  the  inflammatory  process  is  less  apt  to  pro- 
ceed along  that  tube  than  to  extend  into  the  respiratory  tract ; 
and  this,  most  probably,  because  the  flaccid  oesophagus  is  nor- 
mally closed  except  during  the  act  of  deglutition,  and  thus  is  not 
exposed  to  atmospheric  influences  as  the  respiratory  tract  is,  in 
consequence  of  its  permanent  patulousness.  The  continuity  of 
the  pharynx  with  the  digestive  tract  renders  it  liable,  however, 
to  participation  in  diseases  of  the  digestive  apparatus ;  and 
hence  we  frequently  meet  with  pharyngeal  disease  as  a  conse- 
quence of  such  disorders,  especially  when  of  a  chronic  nature. 

The  direct  action  of  cold  is  the  most  frequent  exciting  cause 
of  irritation  leading  to  inflammatory  affections  of  the  pharyngeal 
mucous  membrane,  as  it  is  also  the  most  frequent  exciting 
cause  of  diseases  of  the  respiratory  mucous  membrane ;  and  in- 
stances are  not  seldom  met  with  in  which  irritation  of  this  kind 
leads  to  the  expectoration  of  translucent  sputa,  sometimes  from 
the  pharynx,  sometimes  from  the  larynx,  trachea,  or  bronchi  of 
the  perfectly  healthy  individual,  after  sudden  or  unusual  ex- 
posure to  cold  during  raw  and  inclement  weather.  Such  ex- 
posure, in  a  constitution  run  down  by  overwork,  or  predisjjosed 
to  disease  of  the  throat  by  reason  of  the  scrofulous  or  tubercu- 
lous diathesis,  is  liable  to  lead  to  serious  disease,  which  may  prove 
difiicult  to  overcome,  if  it  does  not  lead  to  permanent  and  fatal 
injuiy. 

The  next  most  fi*equent  source  of  irritation  of  the  mucous 
membrane  of  the  throat  is  the  inhalation  of  solid  or  fluid  parti- 
cles existing  in  the  atmosphere  under  certain  conditions.  These 
act  mechanically  or  chemically  upon  the  structures  with  -which 
they  come  in  contact.     Artisans  exposed  to  the  dust  of  various 


DISEASES    OF   THE   THEOAT   IN    GENERAL.  0 

workshops,  attendants  in  chemical  laboratories,  and  others 
similarly  imperilled,  are  most  apt  to  suffer  in  this  way. 

Another  frequent  source  of  irritation,  eventuating  in  inflam- 
mation of  the  throat  of  a  subacute  or  chronic  character,  is  the 
inhalation  of  an  atmosphere  impregnated  with  the  products  of 
tobacco-smoke.  The  smoking  of  tobacco  is  in  itself  regarded  as 
an  exciting  cause  of  the  affection,  and,  doubtless,  is  so  in  a  great 
many  instances ;  and  even  when  not  in  itself  the  initial  cause 
of  the  disturbance,  has  a  great  deal  to  do  with  its  persistence  and 
chronicity.  Sore  throats,  in  every  way  similar  to  those  attribut- 
ed to  the  effects  of  smoking,  are  met  with  in  individuals  who 
are  not  at  all  addicted  to  the  use  of  tobacco ;  and  a  cause  of 
this  kind  must  be  very  infrequent  in  females,  even  in  regions 
where  the  gentler  sex  indulge  in  a  use  of  the  weed.  The  sitting 
for  hours  at  a  time  in  an  apartment  the  air  of  which  is  charged 
with  the  fumes  of  tobacco,  such  as  is  the  case  in  lager-beer 
saloons  and  concert  saloons,  so  much  resorted  to  by  young  men 
of  native  birth,  and  Germans  of  all  ages,  is  a  much  more  fre- 
quent source  of  disease  in  the  throat  than  the  mere  smoking  of 
tobacco  in  one's  own  house. 

Another  apparent  cause  exists  in  the  promiscuous  use  of  hot 
and  cold  food  and  drink  at  the  same  meal.  Thus  we  partake 
of  hot  soup,  or  drink  hot  coffee  and  tea,  and  cool  the  mouth  and 
throat  by  draughts  of  ice-water  taken  at  intervals  during  the 
meal.  Or,  after  enjoying  a  warm  dinner,  Ave  indulge  in  ice- 
cream or  water-ice,  and  follow  this  by  a  draught  of  hot  coffee. 
This  alternate  application  of  hot  and  cold  to  the  delicate  mucous 
membrane  of  the  throat  can  hardly  fail,  if  persisted  in,  at  least 
to  place  it  in  a  condition  favorable  for  the  inflammatory  process. 
A  similar  treatment  of  the  cutaneous  integument  would  be  quite 
apt  to  induce  an  inflammatory  affection  of  the  skin. 


EXAMINATION    OF   THE   THROAT. 


CHAPTER  11. 

EXAMINATION    OF    THE    THEOAT. 

Ordinary  Inspection.— In  all  cases  of  disease  of  the  throat, 
the  parts  should  always  be  examined  as  carefully  as  the  appli- 
ances at  the  command  of  the  practitioner  will  admit.  It  is 
almost  incredible,  but  is  no  less  the  fact,  that  some  physicians 
treat  their  cases  of  sore  throat  with  no  other  guide  than  that 
furnished  by  the  symptoms  described  by  the  patient.  Again 
and  again  patients  have  come  under  the  author's  care, — and 
his  experience  is  by  no  means  exceptional, — who  had  been 
under  medical  treatment  for  months  without  having  had  their 
throats  examined  even  in  the  most  superficial  manner ;  and 
this  often  in  instances  where  a  mere  glance  would  have  dis- 
covered an  elongated  uvula  or  hypertrophied  tonsils  as  the 
source  of  the  trouble,  which  could  have  been  jDromptly  relieved 
b}^  an  operation  occupying  but  a  few  moments  in  its  execution. 
For  this  there  is  no  excuse.  The  neglect  on  the  part  of  the 
practitioner  is  culpable.  It  is  so  easy  to  depress  the  tongue 
with  the  handle  of  a  spoon,  or  merely  with  the  forefinger,  and 
thus  obtain  a  view  of  the  more  accessible  parts,  that  one  can 
hardly  realize  how  it  can  be  neglected.  There  is  some  excuse 
for  omitting  a  laryngoscopic  or  rhinoscopic  examination  in  the 
early  stages  of  affections  of  the  throat,  inasmuch  as  the  manipu- 
lation requires  a  certain  amount  of  skill  and  practice  Avhich 
every  one  has  not  had  the  opportunity  to  acquire  ;  but  for 
neo-lecting  an  ordinary  inspection  before  a  good  light,  with  the 
tongue  depressed,  there  can  be  no  excuse. 

In  order  to  get  a  good  view  of  the  pharynx  it  is  necessary  to 
depress  the  tongue ;  and  though  the  handle  of  a  spoon  affords 
a  means  of  doing  this,  a  tongue-depressor,  with  a  handle  which 
is  out  of  the  line  of  vision,  is  the  proper  instrument.  The 
ordinary  form  of  the  instrument  is  shown  in  Tig.  1,  and  for  con- 


OEDINARY    INSPECTIOlSr. 


Pig.  1. 


Tongiie-D  epressors. 


venience  in  transportation  tlie  handle  is  made  to  fold  npon  the 
tongue-piece  bj  means  of  a  hinge. 

Sometimes  a  good  deal  of  force  is 
required  to  keep  down  a  muscular 
tongue ;  but  usually,  if  the  blade  is 
laid  lightly  upon  the  organ,  and  gently 
but  firmly  pressed  down  upon  it,  any 
difficulty  of  this  kind  can  be  gradually 
overcome  in  a  few  minutes.  To  gain 
a  good  view  of  the  pharynx,  the  tongue- 
depressor  ought  to  be  long  enough  to 
reach  well  towards  the  base  of  the 
tongue,  and  should  be  hollowed  out 
on  its  under  surface,  or  else  roughen- 
ed, in  order  to  secure  a  better  hold 
on  the  organ.  Smooth-faced  tongue- 
depressors  are  apt  to  slip  forwards  to- 
wards the  tip  of  the  tongue.  By  gradually  pressing  the  base 
of  the  tongue  downwards  and  forwards,  and  at  the  same  time 
causing  the  patient  to  lower  the  chin  more  and  more  upon  the 
breast,  we  can  almost  always  expose  the  entire  lower  portion  of 
the  phar^mx,  and  the  crest  of  the  epiglottis,  or  more  or  less  of 
its  lingual  face.  Sometimes  we  can  even  see  the  upper  circum- 
ference of  the  entire  larynx,  especially  if  the  epiglottis  be 
titillated  with  the  tip  of  the  tongue-depressor  so  as  to  excite  a 
slight  motion  of  gagging.  Some  patients  depress  their  tongues 
and  open  their  mouths  so  well,  that,  looking  down  u^^on  the 
parts,  we  can  see  these  structures  without  the  use  of  any  tongue- 
depressor  at  all.  Cases  are  on  record,  few  in  number,  it  is  true, 
in  which  by  such  voluntary  eifort  of  the  patient  a  view  has 
been  obtained  of  the  interior  of  the  larynx  down  to  the  vocal 
cords ;  and  Tobold  mentions  one  '  in  which  he  was  able  to  see 
the  action  of  the  lips  of  the  glottis  in.  this  manner,  and  also 
to  recognize  a  papilloma  upon  the  left  vocal  cord.  Dr.  Elsberg, 
of  l!^ew  York,  and  Dr.  Boisnot,  of  this  city,  informed  me  in  con- 


^  Lehrbuch  der  Laryngoskopie,  2d  Edition.     Berlin,  1869,  p.  43. 


8  EXAMINATION    OF    THE    THROAT. 

Yersation,  that  they  had  each  come  across  a  case  in  which  they 
could  recognize  the  arytenoid  cartilages  and  the  vocal  cords  in 
this  manner.  I  have  not  yet  had  the  gratification  of  seeing  such 
a  case,  though  I  have  often  seen  the  entire  epiglottis  without 
the  use  of  any  instrument  whatever.  Dr.  Tobold  also  mentions  ^ 
that,  with  the  assistance  of  a  knee-shaped  spatula  which  he  has 
devised  for  exposing  the  pharynx,  he  has  been  able  on  several 
occasions  to  remove  a  fibroid  tumor  situated  in  the  pharynx  at 
the  level  of  the  arytenoid  cartilages,  and  which  he  could  not 

Fig.  2. 


Tobold's  Tongue-depressor.  Xurck's  Tongue-depressor. 

get  at  even  with  the  aid  of  the  laryngoscope.  These  statements, 
surely,  ought  to  convince  practitioners  of  the  value  of  the  use 
of  the  tongue-depressor  as  an  aid  to  diagnosis. 


1  Op.  cit.,  p.  42. 


OEDIN'AEY    INSPECTION.  '  9 

Forms  of  tongue-dej)ressors  especially  adapted  for  the  use  of 
"  unruly  members  "  are  depicted  in  Figs.  2  and  3.  They  are  of 
metal,  with  wooden  handles,  and  are  very  powerful  and  effi- 
cient instruments.  The  apparatus  of  Ttirck  is  provided  with 
several  tongue-pieces  of  different  dimensions,  so  as  to  suit  for 
children,  or  for  adults  with  ver}^  large  and  fleshy  tongues. 

A  tongue-depressor  devised  by  the  author,'  and  shown  in 
Fig.  4,  has  some  advantages  in  special  cases,  and  is  particularly 
efficient  in  exposing  the  pharynx  in  the  manner  already  de- 
scribed. It  is  composed  of  a  single  piece  of  hard  rubber, 
which  recommends  itself  by  the  facility  with  which  it  can  be 
kept  clean  and  sweet — no  slight  desideratum  when  an  instru- 
ment is  fi'equently  exposed  to  the  secretions  from  the  mouth, 
and  to  contact  with  the  various 
caustic   substances   used  in   the  ^°" 

treatment  of  diseases  of  the  throat. 
The  shape  could  be  readily  alter- 
ed at  will  to  suit  any  peculiar 
conformation  of  tongue,  were  this 
ever  necessary,  by  first  holding 
the  instrument  for  a  moment  or 
two  in  boiling  water,  or  over  a 
flame,  so  as  to  render  it  flexible. 
The  tono;ue  portion  is  five  inches         tt  ^    v,^    m 

~  ^  Hard-rubber  Tongue-depressor. 

in  length,  curves  gently  for- 
wards, and  is  considerably  bent  at  its  terminal  extremity,  so  as 
to  embrace  the  posterior  portion  of  the  tongue  in  a  shallow 
depression  about  an  inch  in  length,  scooped  out  of  its  lingual 
surface  at  this  portion,  thus  affording  a  sufficiently  firm  hold 
upon  the  organ.  The  handle,  which  is  of  one  piece  with  the 
blade,  is  bent  downwards  under  the  tongue-piece,  so  that  it 
comes  beneath  the  chin  when  in  use,  and  thus  keeps  the  hand 
out  of  the  way  ;  while  by  drawing  the  handle  forwards  towards 
the  perpendicular,  the  base  of  the  tongue  is  necessarily  pressed 
downwards  and  drawn  forwards,  so  as  to  expose  the  parts  in 


The  Medical Beeord,  Vol.  I.,  1866,  p.  348. 


10  •        EXAMINATION    OF    THE    THEOAT. 

the  freest  manner.  When  well  applied,  it  will  be  no  unusual 
occurrence  to  see  distinctly  the  anterior  or  lingual  surface  of 
the  epiglottis,  with  perhaps  a  portion  of  its  crest,  the  glotto- 
epiglottic  fold,  and  the  lingual  sinuses  at  either  side  ;  and,  of 
course,  a  large  extent  of  the  posterior  and  lateral  walls  of  the 
pharynx,  and  more  or  less  of  the  laryngo-pharyngeal  sinuses. 

LARYNGOSCOPY. 

Within  a  comparatively  recent  period  there  has  been  per- 
fected a  method  of  examining  the  more  remote  structures  of 
the  throat,  by  means  of  an  image  of  the  parts  reflected  upon 
a  small  mirror  placed  within  the  pharynx,  and  held  with  its  re- 
flecting surface  downwards  to  exjjlore  the  lower  structures,  or 
upwards  to  explore  the  upper  structures.  The  former  method 
of  examination,  on  account  of  its  chief  employment  in  the  ex- 
amination of  the  larynx,  is  known  as  laryngoscopy  ;  while  the 
latter  method  has  been  called  rhinoscopy,  inasmuch  as  it  is  most 
frequently  employed  in  examinations  of  the  posterior  nasal 
region. 

For  years  and  years  the  profession  had  felt  the  necessity, 
more  and  more,  for  some  method  of  exploring  the  thi'oat 
better  than  that  afforded  by  mere  inspection  through  the 
open  mouth  with  the  tongue  depressed  ;  and  efforts  to  this  end 
were  made  in  various  directions,  chiefly  to  adapt  for  this  pur- 
pose the  mirror  used  by  the  dentist,  or  some  other  appliance 
acting  on  the  same  principle  of  reflection.  After  many  oft-re- 
peated failures,  success  was  at  last  attained  in  the  production  of 
the  laryngoscope  now  in  common  use,  in  some  one  or  other  of 
its  many  modifications.  We  cannot  spare  space  in  this  volume 
for  more  than  a  fact  or  two  in  the  history  of  the  invention  of 
the  laryngoscope ;  but  as  it  would  be  unjust  to  pass  the  subject 
by  so  summarily,  we  recommend  our  readers  to  two  of  the  best 
and  most  accessible  sources  of  information  on  this  point.* 

The  credit  of  the  first  completel}^  satisfactory  demonstration 
of  the  feasibility  of  examining  the  larynx  in  the  living  subject 

^  Mackenzie ;  The  Use  of  the  Laryngoscope.   2d  and  3d  editions,  London,  1866 
and  1871.     Tobold;  Lehrbuch  der  Laryngoscopie.     2d  edition,  Berlin,  1869. 


LAETNGOSCOPY.  11 

belongs  to  Manuel  Garcia,  a  teacher  of  vocal  music  in  London, 
whose  experiments  and  observations  were  made  solely  in  the 
interests  of  vocal  music.  A  perusal  of  Garcia's  publications 
stimulated  Professor  Ludwig  Tiirck,  of  Vienna,  to  employ  the 
instrument  for  professional  purposes,  but  finding  a  difficulty  in 
its  application,  principally  on  the  score  of  insufiicient  illumina- 
tion, and  being  occupied  at  the  same  time  by  researches  of 
another  nature,  he  gave  up  for  the  time  his  experiments  in  this 
direction.  Prof.  Czermak,  of  Pesth,  borrowed  his  mirrors  from 
Prof.  Tiirck,  and,  conceiving  the  idea  of  employing  artificial 
illumination,  was  enabled  to  perfect  the  application  of  the  in- 
strument; and  he  taught  its  use  to  his  professional  brethren 
throughout  Europe  with  great  zeal,  so  that  he  is  entitled  to  the 
fullest  honor  as  the  chief  promoter  of  the  use  of  the  larjnigo- 
scope  in  medicine.  He  also  conceived  the  idea  of  reversing  the 
position  of  the  mirror,  so  as  to  obtain  an  image  of  the  posterior 
nares  and  naso-pharyngeal  region,  and  thus  invented  the  art  of 
rhinoscopy. 

The  laryngoscope  consists  essentially  of  a  small  mirror,  of 
simple  construction,  which  is  to  be  passed  into  the  pharynx, 
and  held  there  in  such  a  position  that  it'will  reflect  an  image  of 
the  laryngeal  structures  and  parts  adjacent. 

It  thus  permits  the  inspection  of  structures  beyond  the  limit 
of  direct  visual  examination. 

A  good  light  is  an  indispensable  pre-requisite  to  a  laryngo- 
scopic  examination ;  and  when  this  can  be  obtained  from  the  so- 
lar rays,  no  other  appliance  is  required  than  the  simple  mirror. 
This  laryngoscopic  mirror,  as  it  is  called,  is  then  the  only  abso- 
lutely essential  instrument  required  for  laryngoscopic  observa- 
tion. 

When  the  daylight  is  too  feeble  for  our  purpose  we  employ 
certain  appliances,  such  as  lenses  and  reflectors,  to  concentrate 
its  power ;  otherwise^  we  resort  to  the  use  of  artificial  illumina- 
tion. 

Inasmuch  as  it  is  only  at  certain  hours  of  the  day  that  the 
sunlight  is  at  our  convenient  disposal ;  and  inasmuch,  in  addition, 
as  the  peculiarities  of  our  climate  do  not  often  afford  us  the 
opportunity  of  employing  the  sun's  rays  at  the  desired  moment, 


12  EXAMINATION    OF   THE    THROAT. 

or  in  tlie  desired  location,  it  has  been  found  expedient,  by  tliose 
who  have  frequent  occasion  to  use  the  laryngoscope,  to  have  re- 
course to  artificial  illumination  at  all  times.  This  habitual  use 
is  the  more  necessary,  because  parts  appear  redder  and  more 
yellowish  by  artificial  light  than  they  do  by  sunlight;  and 
therefore,  unless  due  allowance  be  made  for  this  difference, 
there  is  danger  that  the  same  condition  which  was  recognized  as 
normal  by  sunlight,  may  appear  as  if  inflamed  when  examined 
by  gas  or  lamp  light,  and  thus  lead  to  the  adoption  of  measures  of 
interference  which  mio-ht  better  have  been  abstained  from. 

The  laryngoscope  has,  in  the  most  literal  sense,  thrown  light 
upon  many  an  obscure  condition  which  would  otherwise  have 
remained  unrecognized,  and  have  been  liable  to  misintei-preta- 
tion  in  the  gloom  of  subjective  investigation  alone.  In  the  case 
of  many  a  despondent  and  all  but  abandoned  sufferer,  it  has 
indicated  a  means  of  rescue  fi'om  the  very  clutch  of  impend- 
ing death. 

The  brilliant  successes  in  laryngoscopic  surgery  have  been  duly 
proclaimed  in  current  medical  literature,  and  have  stimulated 
many  professional  laborers  to  engage  in  the  development  of  the 
same  field  of  usefulness.  The  first  decade  of  larjmgoscopic  re- 
search has  but  recently  passed  its  completion,  and  already  the 
laurels  which  it  has  added  to  the  crown  of  ^sculapius  are 
equal  in  freshness,  imperishability,  and  gracefulness  to  those 
culled  in  any  other  portion  of  his  broad  domain. 

The  literature  which  laryngoscopic  observation  has  tendered 
for  perusal  during  these  ten  or  twelve  years  is  very  extensive, 
and  the  lessons  it  has  taught  have  won  for  it  a  distinguished 
position  among  the  valued  records  of  medical  and  surgical 
learning. 

As  is  perhaps  but  naturally  incident  to  the  development  of  a 
new  subject,  its  zealous  votaries  have  coerced  an  inordinate 
amount  of  ingenuity  in  the  invention  of  novel  appliances  for 
lar}Tigoscopic  examination,  and  still  more  so  in  the  invention 
and  adaptation  of  implements  for  surgical  interference  by  its 
aid.  One  who  has  not  followed  the  subject  closely,  in  all  its 
ramifications,  from  its  very  inception,  can  hardly  realize  the  ex- 
tent to  which  this  instrumento-mania  has  run  rampant. 


LAEYISTGOSCOPY. 


13 


Almost  every  ostensibly  useful  instrument  that  lias  been  de- 
vised in  this  specialty  has  been  subjected  by  the  writer  to  the 
actual  test  of  practice.  Some  of  the  instruments  employed  at 
an  earlier  date  have  been  abandoned  for  others  Fig.  5. 

which  are  more  serviceable.  Many  others  have 
been  found  superfluous ;  and  not  a  few  are 
actually  impracticable  in  application  upon  the 
conscious  subject. 

The  author  will  aim  to  convey  to  the  reader 
the  unprejudiced  results  of  his  own  experience 
in  the  department  of  laryngoscopy.  Only  such 
appliances  as  have  proved  the  most  useful  of 
their  class  will  be  brought  to  notice ;  and  while 
the  endeavor  will  be  made  to  record  nothing 
that  has  not  a  directly  practical  bearing,  care 
will  be  taken,  as  far  as  possible,  to  avoid  the 
omission  of  anything  essentially  useful. 

The  Laryngoscopic  Mirror. — The  form 
of  the  laryngoscopic  mirror  is  not  a  matter 
of  much  importance.  The  very  best  form  is 
that  adopted  by  Prof.  Tiirck  and  depicted  in 
Fig.  5. 

It  is  a  circular  glass  mirror  of  the  finest 
quality,  mounted  in  a  narrow  setting  of  Ger- 
man silver,  and  attached,  at  an  angle  of  120*^, 
to  a  stout  shank  of  the  same  metal ;  a  wooden 
handle  being  attached  to  the  shank.  The 
glass  has  a  diameter  of  one  inch,  and  the  en- 
tire instrument  is  eight  inches  in  length.  This 
mirror  will  meet  almost  every  indication  in 
the  adult.  Occasionally,  and  almost  constantly 
in  children,  a  mirror  of  smaller  diameter  will 
be  required  ;  while  a  mirror  of  much  greater 
dimensions  can  sometimes  be  very  readily 
employed.  It  is  obvious  that  the  larger  the 
mirror  that  can  be  used  in  any  case,  the  more 
satisfactory  will  be  the  examination.  When 
enlarged    tonsils  protrude  into  the   isthmus 


Laryngoscopic  Mirror 
of  Circular  Form, 


14 


EXAMITTATION    OF   THE    THKOAT. 

Fig.  6. 


SIDE  AND  FEONT  VIEWS  OF  LABTNGOSCOPIC  MIEKORS  OF  DIFFEEENT  FOEMS  AND  SIZES 
!  (AFTEE  TOBOLD). 

1,  2,  5.  Ordinary  mirrors. 

3,  4.  Mirrors  with  stem  to  the  side. 

6.  Oval  mirror  for  use  in  cases  of  enlarged  tonsils. 
Side  view  of  Tiirck's  circular  mirror. 


LAEYITGOSCOPY.  15 

of  tlie  pharynx,  a  mirror  oval  in  its  vertical  diameter  mnst  be 
nsed,  in  order  to  pass  these  glands  and  reach  the  posterior  wall 
of  the  pharynx.  Under  these  circumstances  we  may  employ  a 
mirror  an  inch  in  length,  and  from  fi^•e-eighths  to  seven-eighths 
of  an  inch  in  its  broadest  transverse  diameter. 

In  order  to  be  enabled  to  examine  all  classes  of  cases  as  the}^ 
usually  come  under  observation,  the  practitioner  should  be  pro- 
vided with  at  least  four  mirrors :  three  circular  ones  of  five- 
eighths,  three-quarters,  and  one  inch  diameter  respectively,  and 
one  oval  one  of  five-eighths .  inch  transverse  diameter.  Other 
mirrors  may  be  better  adapted  to  exceptional  cases,  but  such 
cases  are  rare.  Should  but  a  single  mirror  be  desired,  the  inch- 
mirror  should  be  selected,  as  apt  to  fulfil  the  greatest  number 
of  indications. 

Some  observers  have  recommended  square  and  dome-shaped 
mirrors,  with  the  shank  soldered  at  one  corner.  There  is 
no  objection  to  their  use  ;  but,  as  a  rule,  the  circular  mirrors 
will  be  found  to  be  better  borne  by  the  patient.  It  has  also 
been  recommended  that  we  should  have  mirrors  at  hand  sol- 
dered- to  the  stem  at  various  angles,  as  more  likely  to  meet 
varying  indications.  This  is  altogether  unnecessary,  for  a  slight 
motion  of  the  fingers  and  wrist  will  enable  the  observer  to  give 
the  mirror  any  inclination  he  may  desire  after  introducing  it, 
and  the  emergency  is  thus  provided  for. 

A  mirror  firmly  soldered  to  its  handle  is  preferable  to  one  in 
which  the  stem  is  made  to  slide  in  and  out. 

Some  observers  have  expressed  a  preference  for  a  mirror  with 
an  acuter  angle  of  attachment  to  its  stem.  This  is  altogether  a 
matter  of  choice.  It  is  really  an  affair  of  little  moment  whether 
the  angle  is  a  little  greater  or  a  little  less ;  for  it  is  to  be  pre- 
sumed that,  once  familiar  with  the  use  of  the  instrument,  an 
expert  manipulator  could  employ  any  mirror  to  which  he  might 
have  access. 

An  extensive  experience  with  mirrors  of  every  description 
has  demonstrated,  in  the  most  practical  manner,  that  the  habitual 
employment  of  the  mirror  at  an  angle  of  120°,  as  first  adopted 
by  Tiirck,  will  fulfil  nearly  every  indication. 

The  quality  of  the  reflecting  surface,  however,  is  a  matter  of 


16  EXAMIISTATION    OF   THE    THROAT. 

considerable  importance.  A  laryngoscopic  mirror  sliould  afford 
a  perfect  image.  Its  qnality  may  be  tested  by  holding  it  over  a 
piece  of  white  paper.  The  reflection  should  be  perfectly  white ; 
if  it  be  bluish  or  yellowish,  the  laryngeal  image  will  be  sure  to  lose 
in  distinctness  in  proportion  to  the  departure  from  a  pure  white, 
and  thus  to  vary  somewhat  from  the  normal  color  of  the  parts. 

Laryngoscopic  mirrors  have  been  constructed  from  steel  which 
has  then  been  highly  polished,  and  from  other  metals  with  sur- 
faces of  great  lustre.  These  are  very  serviceable  while  new  and 
unscratched,  though  presenting  a  violetish  tinge  to  the  reflec- 
tion of  white  paper ;  but  they  soon  become  tarnished  by  usage, 
and  are  kept  in  order  with  difticulty.  They  are  applicable  only 
to  special  cases  in  which  but  a  very  small  mirror  can  be  em- 
ployed, and  when  it  is  a  matter  of  some  moment  to  avoid  the 
loss  of  reflecting  surface  which  even  the  narrowest  setting  would 
sacrifice  in  the  glass  mirror.  Such  a  case  occurs  when  it  is 
necessary  to  make  an  examination  through  an  artificial  opening 
in  the  trachea. 

Introduction  of  the  Mirror. — The  position  of  the  mirror  in 
the  pharynx  of  the  patient,  its  manner  of  introduction,  and  the 
character  of  the  image  which  is  seen  upon  it  when  in  position, 
is  depicted  in  Fig.  7.  The  mirror  is  represented  as  having  been 
placed  at  an  angle  of  about  45°  with  the  plane  of  the  larynx ; 
but  its  position  in  practice  will  vary  in  different  individuals,  in 
consequence  of  peculiarities  of  conformation.  Much,  too,  will 
depend  upon  the  degree  of  flexion  given  to  the  patient's  head,  the 
position  of  the  observer's  eye,  and  other  contingencies  which  will 
become  aj3parent  as  we  proceed  in  the  discussion  of  the  subject. 

The  manner  in  which  the  laryngoscopic  mirror  is  most  conve- 
niently used  is  as  follows : — 

The  patient  is  seated  in  a  chair  in  such  position  that  a  strong 
light  shall  illumine  the  pharynx,  and  especially  the  lower  por- 
tion of  the  soft  palate.  This  examination  may  be  made  in  the 
open  air,  before  a  window,  or  in  front  of  a  lamp  or  other 
artificial  light.  The  observer  seats  himself  in  front  of  his 
patient,  at  such  distance  as  to  obtain  distinct  and  clear  vision 
of  the  soft  palate  and  the  posterior  wall  of  the  pharynx. 
The    head    of    the    patient    should    be   kept   erect,   or  very 


LARYJNTGOSCOPT. 


17 


sliglitly  bent  backwards.  The  position  may  have  to  be  varied 
from  tlie  one  to  the  other  after  the  mirror  has  been  intro- 
duced ;  but  for  the  majority  of  cases  a  favorable  position  will 


The  laryngoscopic  mirror  in  position. 

be  such  a  one  as  shall  place  the  lower  border  of  the  upper  incisor 
teeth  upon  a  horizontal  plane  with  the  base  of  the  soft  palate. 
The  mouth  should  be  widely  distended,  and  the  tongue  thrust 
forward  towards  the  chin  with  considerable  muscular  force,  its 
body  lying  upon  the  floor  of  the  mouth,  and  its  posterior  por- 
tion and  base  rendered  as  concave  as  possible.  In  this  position 
2 


18 


EXAMIN-ATIOlSr    OF   THE    THROAT. 


Fig.  8. 


it  may  be  enveloped  in  a  handkerchief  or  napkin,  and  held  by 
the  observer  or  the  patient  himself,  as  most  convenient ;  the 
napkin  being  interposed  to  .jDrevent  the  tongue  slipping  back 
from  between  the  thumb  and  fingers.  The  patient  should 
breathe  rather  deeply,  but  quietly,  synchronously,  and  without 
effort. 

The  stem  of  the  mirror  should  be  taken  in  the  hand  in  the 
manner  of  handling  a  pen  or  lead-pencil,  the  wrist  being  well 
extended,  though  not  stiffly  so,  the  mirror  pointing  upwards,  with 
its  reflecting  surface  horizontal  and  looking  downwards,  as  de- 
picted in  Fig.  8. 

The  patient  being  told  to  take  a  deep  inspiration,  so  as  to  raise 

the  palate,  the  laryngoscopic 
mirror  is  passed  well  above  the 
tongue,  directly  backwards,  until 
it  reaches  the  uvula,  when,  receiv- 
ing the  uvula  on  the  back  of  the 
mirror,  the  wrist  is  flexed,  and 
the  mirror  landed  with  its  lower 
border  on  the  posterior  wall  of 
the  pharynx ;  the  uvula  and  soft 
palate  being  pushed  backwards 
and  somewhat  upwards  in  the 
manoeuvre.  The  stem  of  the  mir- 
ror is  now  horizontal,  and  the 
reflecting  sui-f ace  looks  oblique- 
ly downwards  and  forwards. 
When  the  palate  is  raised  very  high  during  a  deep  inspiration, 
the  mirror  can  be  placed  in  position  without  pressing  upon  it,  and 
then,  as  expiration  is  effected,  the  palate  falls  gently  upon  the 
back  of  the  mirror.  This  method  of  procedure  will  be  found 
serviceable  in  the  examination  of  nervous  individuals. 

The  mirror  being  properly  introduced,  we  perceive  in  it  an 
image  of  the  larynx  and  adjacent  structures,  but  in  a  reversed 
position,  though  not  an  inverted  one  ;  that  is  to  say,  those  struc- 
tures which  are  posterior  in  reality  are  anterior  in  the  image, 
and  what  is  really  in  front  looks  as  if  it  were  behind,  the  rela- 
tive positions  of  right  and  left  being  unchanged.  ■ 


Manner  of  holding  laryngoscopic  mirror  pre- 
vious to  its  introduction. 


LARYJSTGOSCOPY. 


19 


This  condition  of  things  will  be  rendered  intelligible  at  a 
glance  by  consulting  the  accompanying  illnstration,  Fig.  9. 

The  structures   (base  of 
tongue,     and     epiglotti s)  ^°'  ' ' 

which  are  above  and  in 
front  in  the  patient,  appear 
above  and  behind  in  th( 
mirror ;  the  parts  (arytenoid 
cartilages,  etc.)  which  ari 
below  and  behind  in  the 
patient,  appear  below  and 
in  front  in  the  mirror ;  but 
the  structures  which  are  in 
reality  on  the  right  hand  of 
the  observer  in  the  patient, 
are  on  his  right  in  the  mir- 
ror also.  In  other  words, 
those  parts  nearest  the  mir- 
I'or  are  seen  as  if  they  were 
nearer  the  observer,  who 
views  them  very  much  as 
he  woidd  do  if  he  could  look 
at  them  from  behind  with 
his  eye  in  the  position  of 
the  laryngeal  mirror. 

The  lower  figure  represents  a  view  of  the  base  of  the  tongue 
and  the  larynx  in  the  relative  position  they  bear  in  the  person 
who  is  being  examined,  while  the  upper  figure  shows  the  im- 
age as  seen  in  the  mirror.  If  the  reader  will  hold  a  laryngosco- 
pic  mirror  (or,  in  lieu  of  it,  a  piece  of  looking-glass)  obliquely 
above  the  lower  figure  and  behind  it,  so  as  to  receive  its  reflec 
tion,  he  will  get  some  such  an  image  as  is  pictured  in  tlie  upper 
figure.  This  diagram  will  be  found  useful  in  studying  tJie  rela- 
tion of  parts  in  actual  practice. 

There  are.certain  important  points  in  reference  to  the  intro- 
duction of  the  laryngoscopic  mirror  which  require  elucidation 
with  some  detail. 

The  mirror  must  be  warmed  before  it  is  passed  into  the 
mouth.     If  introduced    cold   it   will   become   blurred  by  the 


Relative  relations  of  laryns   and  its  image  in   the 
laryngoscopic  mirror. 


20  EXAMIjS^ATIOlSr    OF    THE    THROAT. 

halitus  of  the  breath,  and  we  will  only  be  able  to  obtain  an  in- 
termittent indistinct  view,  as  each  successive  inspiration  clears 
the  glass  of  some  of  the  moisture  condensed  upon  it.  To  avoid 
this  result,  we  heat  the  mirror  before  introducing  it.  Various 
methods  have  been  devised  for  this  purpose,  some  of  them  in- 
geniously ridiculous,  such  as  keeping  an  electric  current  travers- 
ing the  mirror ;  but  it  is  only  necessary  to  mention  the  best  me- 
thod, and  that  is  to  heat  the  reflecting  surface  over  a  flame.  In 
this  way  the  mounting  is  not  so  apt  to  become  warm  enough  to 
burn  the  tissues.  We  avoid  burning  the  patient  by  testing  the 
back  of  the  mirror  on  the  hand  or  cheek  before  introducing  it 
into  the  pharynx.  Care  must  be  taken  not  to  heat  the  mirror 
too  mucli,  for  that  will  cause  the  amalgam  to  run  and  thus  de- 
stroy its  reflecting  power.  All  that  is  required  is  a  gentle 
warmth,  under  the  influence  of  which  the  mirror  will  remain 
untarnishable  for  several  minutes.  If  a  cold  mirror  is  placed 
over  a  flame,  the  moisture  of  the  apartment  condenses  on  its 
surface  immediately,  and  is  then  gradually  evaporated  from  cir- 
cumference to  centre.  The  moment  the  mirror  clears,  it  M'ill 
be  fit  for  use.^  This  usually  occupies  but  a  couple  of  seconds, 
the  time  varj^ing  with  temperature  and  season. 

If  the  mirror  is  not  well  made,  the  heat  will,  after  a  while, 
affect  the  coating  and  destroy  its  reflecting  power ;  and  this  is 
particularly  the  case  with  the  common  quicksilvered  mirrors, 
which  are  thus  soon  rendered  unfit  for  use. 

AVe  must  not  retain  the  mirror  too  long  at  a  time  in  the 
mouth.  It  is  better  to  reintroduce  it  several  times,  than  to 
fatigue  the  parts  by  keeping  them  too  long  in  a  constrained  po- 
sition. In  this  way  we  avoid  the  induction  of  congestion,  or  of 
irritability  and  spasm. 

Impediments  to  the  Examiination. — Ordinarily  there 
should  be  no  difiiculty  whatever  in  immediately  effecting  a  sat- 
isfactory laryngoscopic  examination,  at  the  hands  of  any  one 
possessing  moderate  skill  in  the  use  of  the  instrument. 

Occasionally,  however,  impediments  are  presented,  a  consid- 
eration of  which  is  necessary. 

1  For  this  hint  the  author  is  iadebted  tc  Dr.  Elsberg,  of  New  York.  The 
Medical  Eecord^  vol.  i.,  p.  276. 


LARYISTGOSCOPY.  21 

There  may  be  unwillingness  or  inability  to  open  the  mouth 
properly.  ISTow  it  is  very  necessary  that  the  mouth  should  be 
wide  open,  the  wider  the  better.  Some  patients  can  open  the 
mouth  well  enough,  but  they  close  it  involuntarily  as  soon  as 
the  attempt  is  made  to  pass  in  an  instrument.  If,  after  a  little 
moral  persuasion,  it  is  found  impossible  to  keep  the  patient's 
mouth  open  wide  enough,  we  resort  to  a  mouth  distender  or  spec- 
ulum, and  pass  the  laryngoscopic  mirror  through  it.  Of  these 
there  are  many  forms,  A  short  glass  speculum,  similar  to  that 
employed  by  the  obstetrician,  but  unsilvered  and  not  blackened, 
about  an  inch  and  an  eighth  in  diameter,  will  answer  the  indi- 
cation, and  permit  tlie  passage  of  an  ordinary  mirror.  Under 
these  circumstances  the  tongue  is  retained  in  the  mouth,  and  is 
kept  depressed  by  the  position  of  the  speculum.  Trouble  of  this 
kind,  however,  is  infrequent,  and  the  practitioner  will  rarely 
have  occasion  for  the  use  of  a  mouth  distender  ;  though  it  may 
be  mentioned  in  passing  that  such  a  contrivance  will  be  found 
highly  convenient  in  making  applications  to  the  throats  of  re- 
fractory patients. 

The  management  of  the  tongue  sometimes  becomes  a  matter 
of  considerable  annoyance.  At  the  commencement  of  a  laryn- 
goscopic examination  it  will  often  be  found,  too  truly,  an  un- 
ruly member.  The  position  of  the  organ  most  favorable  for 
the  purpose  is  obtained  when  it  is  moderately  protruded  by 
the  action  of  its  own  muscles,  its  body  resting  quietly  upon 
the  floor  of  the  mouth,  and  its  base  guttered  into  a  broad  sulcus. 
It  requires  some  practice  for  the  majority  of  individuals  to  ac- 
custom themselves  to  maintaining  the  tongue  in  this  position, 
but  the  ability  to  do  so  is  readily  acquired  by  frequent  practice, 
especially  before  the  glass. 

Then  again,  the  tongue  often  rises  up  involuntarily  as  soon 
as  any  foreign  body  passes  the  teeth,  and  it  may  rise  sufliciently 
to  push  the  mirror  to  the  very  roof  of  the  mouth.  It  is  neces- 
sary that  the  base  of  the  tongue  should  be  directed  forwards 
and  downwards,  so  as  to  increase  the  pharjmgeal  space,  and  to 
draw  the  epiglottis  up  by  the  tension  on  the  glotto-epiglottic 
ligament  ;  for  the  epiglottis  in  most  people  overlooks  the  la- 
ryngeal   aperture,   and,  unless    moderately   erect,   it   will,   to 


22  EXAMINATION    OF   THE    THROAT. 

a  greater  or  lesser  extent,  intercept  the  view  of  the  iiitra- 
laryngeal  structures.  It  is  an  excellent  plan  to  instruct  the 
patient  to  hollow  his  tongue  at  the  base,  and  then  thrust  it 
forcibly  forwards  out  of  the  mouth  ;  when,  if  he  cainiot  main- 
tain it  in  this  position  without  aid,  it  may  be  held  by  the  thumb 
and  fingers  of  the  disengaged  hand  of  the  observer,  guarded  by 
a  glove,  handkerchief,  or  napkin ;  or,  what  is  more  convenient,  for 
many  reasons,  the  tongue  may  be  intrusted  to  the  patient's  own 
fingers.  The  fingers  of  the  patient  in  holding  his  tongue  should 
be  applied  above  and  the  thumb  below,  and  he  should  use  the 
right  hand  when  the  observer  intends  to  hold  the  laryngoscopic 
mirror  in  his  own  right  hand,  and  vice  versa.  This  will  keep 
the  fingers  out  of  the  way.  The  tongue  should  not  be  pulled 
downwards  with  any  force,  lest  the  fra^num  be  injured  by  pres- 
sure upon  the  incisor  teeth.  If  any  result  of  this  kind  is  to  be 
apprehended,  it  may  be  prevented  by  the  interposition  of  a 
compress.  A  great  deal  of  ingenuity  has  been  manifested  in 
the  invention  of  tongue-depressors  and  tougue-forceps  for  the 
purpose  of  retaining  the  tongue  in  the  desired  position.  The 
employment  of  any  mechanical  contrivance  whatever  for  hold- 
ing the  tongue  is  greatly  to  be  deprecated,  and  should  be  avoid- 
ed as  a  rule.  Occasionally  it  does  seem  impossible  to  get  along 
without  something  of  the  kind,  but  the  alternative  is  to  be 
acknowledged  with  reluctance. 

If  the  tongue  is  so  fieshy  that  it  occupies  too  much  space  in 
the  cavity  of  the  mouth,  or  so  restless  that  it  keeps  bobbing 
about,  we  can  often  press  it  down  or  restrain  its  movements  by 
the  simple  contact  upon  it  of  a  pen-handle,  pocket-probe,  or  eveji 
the  forefinger  ;  something  to  steady  it,  as  it  were. 

At  times,  however,  a  tongue-depressor  is  indispensable.  The 
tono-ue-depressor  in  ordinary  use  is  not  suitable  for  the  purposes 
of  laryngoscopy,  inasmuch  as  it  depresses  the  anterior  portion 
of  the  tongue  merely,  forcing  the  base  backwards  upon  the 
epio"lottis — the  very  effect  we  wish  to  avoid.  Nor  should  we  use 
one  that  is  fenestrated,  for  it  permits  a  portion  of  the  tongue  to 
rise  through  the  fenestrum,  thereby  intercej)ting  the  view. 

The  tongue-depressor  pictured  in  Fig.  4  is  believed  to  fill  at 
least  eNcry  indication  claimed  for  many  of  the  more  elaborate 


LAEYNGOSCOPY.  23 

and  complicated  appliances  that  have  been  invented  for  the 
same  purpose.  The  handle,  being  bent  U]?on  the  tongue-portion 
at  an  angle,  turns  in  towards  the  neck  when  the  instrument  is 
applied  to  the  tongue  ;  thus  the  hand  in  which  it  is  held  is  kept 
out  of  the  observer's  way ;  while,  bj  bringing  the  handle  forward 
towards  the  perpendicular,  the  base  of  the  tongue  is  necessarily 
pressed  downwards  and  drawn  forwai-ds,  elevating  the  epiglottis, 
and  securing  a  favorable  position  for  successful  examination. 

This  instrument,  or  a  substitute,  frequently  introduced  by  the 
patient  at  home,  will  overcome  sensibility  of  the  base  of  the 
tongue,  whether  preternatural  or  ordinary. 

With  such  a  tongue-depressor,  properly  constructed  and  well 
applied,  it  will  be  no  unusual  occurrence  to  expose  at  once  to 
direct  vision  the  lingual  surface  of  the  epiglottis  with  more  or 
less  of  its  crest,  the  glotto-epiglottic  ligament  or  fold,  and  the 
lingual  sinuses  at  either  side  ;  and,  of  course,  a  large  extent  of 
the  pharynx.  Once  in  position,  it  can  be  very  advantageously 
intrusted  to  the  management  of  the  patient.  It  is  to  be  under- 
stood, however,  that  this  tongue-depressor  is  not  recommended 
for  habitual  use.  It  is  better  to  avoid  every  artificial  means  to 
hold  the  tongue,  and  we  can  avoid  doing  so  in  nearly  every 
case,  if  time  permits.  A  little  practice  will  enable  the  patient 
to  maintain  his  tongue  in  a  favorable  position  ;  and  as  contact 
with  the  organ  can  be  avoided  in  the  introduction  of  the  mirror 
by  the  motion  of  flexion  of  the  wrist,  as  already  described,  the 
tongue-spatula  can  almost  always  be  dispensed  with. 

"  Irritability  of  the  fauces  "  is  another  obstacle  occasionally 
presented,  though  by  no  means  as  frequently  as  is  ordinarily  ima- 
gined. Nearly  every  unsuccessful  attempt  at  laryngoscopic  ex- 
amination attributed  to  this  cause  is  due  to  irritability  in  the  hand 
of  the  manipulator,  and  this  may  arise  from  want  of  skill  and 
want  of  patience  on  the  part  of  the  examiner.  This  once  over- 
come, irritability  of  the  fauces  will  cease  to  present  any  embar- 
rassment. Sometimes,  however,  there  does  exist  a  great  deal 
of  irritability  of  parts,  and  occasionally  to  a  considerable  de- 
gree, but  the  instances  are  few  and  far  between.  It  may  often 
be -overcome  by  impressing  the  patient  with  the  necessity  of 
controlling  it  by  strong  mental  effort.     Gentle  manipulation 


24  EXAMINATION    OF    THE    THEOAT. 

of  the  parts  with  a  probe  or  grooye-di rector  will  often  succeed. 
Astringent  and  other  solutions  may  be  applied  locally  to  the 
parts.  If  time  is  not  of  much  importance,  and  other  circum- 
stances permit,  large  doses  (30  to  60  grs.)  of  bromide  of  potas- 
sium may  be  given,  at  intervals  of  three  or  four  hours,  for 
three  or  four  successive  doses  ;  and  they  will  be  found  occa- 
sionally to  induce  a  considerable  amount  of  tolerance  of  mani- 
pulation. Gargles,  and  sprays  of  alum,  tannin,  bromide  of 
potassium,  and  bromide  of  ammonium ;  sprays  of  sulphuric 
ether,  rhigolene  and  chimogene ;  pencillings  with  astringents 
and  caustics ;  pencillings  with  solutions  of  morphia  in  chloro- 
form ;  the  local  contact  of  small  bits  of  ice  ;  the  inhalation 
of  from  ten  to  twenty  drops  of  chloroform,  and  a  still 
longer  list  of  other  methods  have  been  recommended  for  this 
purpose.  Many  of  the  most  inefficient  of  these  have  been 
those  most  highly  extolled,  perhaps  from  having  chanced  to 
succeed  in  the  only  case  in  which  they  were  tried.  Of  all  these 
devices  the  best  are  the  contact  of  the  nebulized  spray  of  a 
solution  of  tannin,  and  the  inhalation  of  a  few  whiffs  of  chloro- 
form. But  the  most  judicious  plan  will  be  found  to  consist  in 
overcoming  the  sensibility  of  the  parts  by  repeated  contact 
of  the  laryngoscopic  mirror. 

The  writer  some  years  ago  expressed  the  opinion '  that  this 
irritability  of  tongue  and  fauces  is  in  the  main  due  to  indiges- 
tion, and  often  attendant  upon  the  digestive  act  itself.  Hence 
he  adopted  the  simple  plan  of  not  making  the  examination  in 
such  cases  until  three  or  four  hours  after  a  meal.  This  expe- 
dient has  been  found  to  answer  its  purpose  in  a  large  propor- 
tion of  instances.  When  marked  disorder  of  the  digestive 
apparatus  exists,  a  smart  purge  administered  the  night  previous 
will  lessen  the  sensibility  of  the  parts  the  next  morning. 

Enlargement  of  the  tonsils  may  prevent  the  introduction  of 
the  circular  mirror,  and  render  the  employment  of  an  oval  one 
necessary.  If  the  mirror  used  be  broader  than  the  space  be- 
tween the  hypertrophied  glands,  it  is  to  be  pushed  right  back 


1  The  Medical  Record.     1866,  vol.  i.,  p.  349. 


LAETNGOSCOPY.  2o 

between  them  and  behind;  and  ahhongh  they  cover  the  side  of 
the  mirror  somewhat  in  resuming  their  position,  sufficient  re- 
flecting surface  nsually  remains  exposed  to  permit  of  a  satis- 
factory examination.  The  movement  of  passing  the  tonsils 
must  be  done  with  great  celerity,  and  it  is  then  hardly  recog- 
nized by  the  patient.  If  the  tonsils  are  hypertrophied  to  such 
an  extent  as  to  preclude  the  introduction  of  the  oval  mirror, 
they  must  be  excised. 

Elongation  of  the  uvula  may  become  a  source  of  difficulty,  by 
hanging  below  the  mirror,  reflecting  its  own  image,  and  inter- 
cepting the  view  of  the  parts  to  be  examined.  If  it  cannot  be 
retracted  by  titillation  or '  astringent  applications,  the  exuber- 
ant portion  must  be  clipped  off. 

An  unfavorable  position  of  the  epiglottis  is  a  much  more 
serious  obstacle  than  any  w4iich  has  yet  been  discussed.  Here, 
Nature  has  occasionally  placed  an  impediment  to  laryngoscopic 
examination.  Sometimes  as  a  congenital  conformation,  some- 
times as  the  result  of  cicatrization,  sometimes  as  an  acquisition 
dependent  npon  a  vicious  mode  of  utterance  in  public  speaking, 
we  once  in  a  wdiile  meet  with  a  depressed  epiglottis,  which 
overhangs  the  vestibule  of  the  larynx  to  such  an  extent  as  to 
preclude  the  passage  of  light  to  its  interior.  When  this  con- 
dition exists  in  but  a  sliglit  degree,  and  more  especially  in 
acquired  cases,  it  may  be  overcome  by  frequently  pulling  the 
valve  forward  with  the  finger.  The  patient  can  very  readily 
be  instructed  to  do  this  for  himself.  Or  we  may  pass  a  suitably 
shaped  broad  blnnt  hook  behind  the  epiglottis  and  pull  it  for- 
ward. Very  often  we  can  gain  a  momentary  view  into  the 
larynx  by  causing  the  patient  to  make  an  ironical  laugh,  or  to 
make  a  vocal  sound  during  inspiration,  or  to  make  a  sndden 
inspiration,  or  to  utter  the  sound  eh  with  a  very  high  pitch. 
These  movements  throw  the  epiglottis  upward  for  the  moment. 

Where  we  wish  to  make  a  thorough  examination  under  these 
circumstances,  or  even  a  superficial  examination  in  bad  cases  of 
this  condition,  we  must  resort  to  some  mechanical  contrivance 
to  raise  the  epiglottis  forciblj  and  maintain  it  in  an  erect  posi- 
tion. One  of  the  best  is  a  stont  rod  bent  nearly  to  a  right  angle 
at  its  extremity  for  about  an  inch,  with  the  terminal  point  turned 


26 


EXAMIISTATION    OF   THE    THROAT. 


backwards.  If  we  are  merely  making  a  diagnosis,  we  intrust 
the  tongue  to  the  patient  himself,  and  introducing  the  laryngeal 
mirror  with  one  hand,  with  the  other  introduce,  by  the  aid  of 
the  reflection  in  the  laryngeal  mirror,  this  rod  or  staff  (Voltolini's 
staff)  beyond  the  epiglottis,  against  the  laryngeal  face  of  which 
the  bent  portion  is  to  be  pressed,  and  as  the  rod  is  drawn  for- 
Pjg  iQ  ward,  the  epiglottis  will  be  forcibly  raised  and 

held  in  position.  The  terminal  point  of  the 
rod  which  is  turned  off  from  the  rest  of  the 
hooked  end  cannot  press  against  the  epiglottis, 
and  thus  the  pain  of  the  operation  is  lessened. 
A  stout  whalebone  rod  squared  at  the  bent 
portion  ^vill  answer  the  purpose  admirably. 
The  introduction  of  this  staff  requires  a  good 
deal  of  skill.  The  manipulation  must  be  made 
quietly,  but  with  a  firm  though  gentle  touch. 
We  need  not  handle  the  parts  roughly  just 
because  we  must  take  a  decided  hold  of  them. 
When,  however,  an  application  is  to  be  made 
within  a  larynx  with  a  depressed  epiglottis, 
we  need  an  appliance,  which,  when  in  posi- 
tioji,  can  be  held  by  the  patient  or  left  to  itself, 
for  we  \nll  have  both  hands  employed  with 
other  instruments.  For  this  purpose  epiglot- 
tic pincettes,  forceps,  hooks,  needles,  snares, 
etc.,  have  been  devised,  to  seize  the  epiglottis 
and  hold  on  to  it.  It  is  no  easy  matter  to 
seize  the  epiglottis,  pierce  it  with  a  threaded 
needle,  and  thus  control  it ;  it  is  not  even 
easy  to  seize  it  with  toothed  forceps.  And 
when  seized  in  this  way,  it  is  very  intolerant 
of  the  manipulation.  The  forceps  and  pin- 
cettes devised  for  holding  the  epiglottis  are 
intended  to  hang  on  to  it  during  an  operation, 
and  keep  it  erect  by  their  weight.  One  of  the 
most  convenient  instruments  for  this  purpose  is  the  toothed 
forceps  of  Yon  Bruns,  depicted  in  Figure  10.  The  edge  of  the 
epiglottis  is  seized  between-  tlie  seiTated   blades,  which   close 


Von  Bnins'  pincette 

for  holding  up  the 

epiglottis. 


LARYNGOSCOPY.  27 

tightly  upon  it  when  pressure  is  taken  from  the  spring  handle, 
and  the  instrument  is  allowed  to  hang  out  of  the  mouth  during 
an  operation.  A  reliable  instrument  for  managing  a  depressed 
epiglottis  has  not  yet  been  in%'ented. 

These  instruments,  however,  require  care  and  discretion  in 
their  employment,  for  Schrotter,  than  whom  there  are  but  few 
more  skilful  laryngoscopists,  lost  a  case  from  extensive  laryngeal 
oedema  consequent  upon  the  use  of  Yon  Bruns'  instrument  for 
raising  the  epiglottis/ 

When  the  depression  of  the  epiglottis  has  been  produced  by 
the  contraction  of  cicatricial  tissue,  this  must  be  divided  by 
one  of  the  instruments  to  "be  described  in  the  sequel. 

The  manner  of  breathing  sometimes  presents  an  impediment 
to  the  examination.  Nervous  individuals  are  excited  by  the 
paraphernalia  incident  to  a  laryngoscopic  examination,  espe- 
cially if  by  artificial  light,  and  are  apt  to  breathe  in  a  hurried, 
constrained,  or  spasmodic  manner.  This  irregular  respiration 
must  be  overcome  preparatory  to  a  successful  result.  By 
breathing  in  time  with  the  patient ;  by  accompanying  the 
breathing  at  first  with  a  sound  allowed  to  become  less  and  less 
audible  as  respiration  progresses;  by  beating  time,  or  by  some 
similar  method,  we  control  the  excitability  of  the  patient,  and 
then  proceed  to  the  examination  as  quietly  and  as  gently  as 
possil^le. 

In  fact,  the  great  secret  of  success  in  laryngoscopic  examina- 
tion is  to  take  time  for  it,  and  to  have  patience  with  the  patient. 
It  is  useless  to  hurry  a  patient  or  to  scold  him  roundly,  for  this 
only  excites  him  the  more,  and  the  greater  the  excitement  or 
dread  under  which  he  is  laboring,  the  greater  is  his  susceptibility 
to  spasm  from  the  contact  of  the  mirror.  If  time  enough  can- 
not be  devoted  to  the  object  to  proceed  deliberately,  the  attempt 
had  better  be  abandoned,  or  postponed  to  a  more  convenient 
period. 

In  view  of  overcoming  the  sensibility  of  the  pharynx  and 
palate, — parts  which  are  pressed  upon  during  a  laryngoscopic  ex- 
amination,— and  thus  securing  a  more  prolonged  tolerance  of  the 

1  Medizinische  Jahrbiicher,  1868,  sv.  Bd.  p.  73. 


28  EXAMINATIOlSr    OF    THE    THEOAT. 

presence  of  the  mirror,  it  has  been  suggested  to  resort  to  the  in- 
duction of  anaesthesia.  Complete  anaesthesia  is  not  applicable 
to  the  requirements  of  larjngoscopic  manipulations,  because  we 
desire  to  maintain  the  head,  mouth,  and  tongue  in  certain  posi- 
tions, and  it  is  necessary  in  almost  every  examination,  and  much 
more  so  in  the  performance  of  a  laryngeal  operation  through 
the  mouth,  to  avail  ourselves  of  the  co-operation  of  the  patient, 
whom  we  direct  to  make  this  or  the  other  physiological  move- 
ment, which  will  raise  the  epiglottis,  depress  the  tongue,  ap- 
proximate or  separate  the  vocal  cords,  etc.,  in  order  to  bring 
into  view  certain  structures  which  would  otherwise  remain  out 
of  the  line  of  vision. 

Apparatus  to  increase  the  lUumination. — It  has  already 
been  stated  that  a  good  light  is  an  indispensable  pre-requisite  to 
a  laryngoscopic  examination.  The  manipulation  of  the  laryn- 
goscopic  mirror  is  substantially  the  same,  no  matter  whence  the 
source  of  light  may  be  derived. 

It  is  only  during  a  sliort  period  of  day,  while  the  sun's  rays 
incline  to  the  horizontal,  that  we  are  enabled  to  avail  ourselves 
of  direct  sunlight,  the  brightest  illumination  that  we  can  em- 
ploy. 

When  the  time  of  day,  or  location  of  the  examining-room,  is 
unfavorable  to  the  utilization  of  the  direct  light  of  the  sun,  we 
may  reflect  the  rays  to  the  desired  point  by  receiving  them  upon 
a  small  plain  looking-glass  ca]3able  of  being  turned  obliquely  in 
the  desired  direction.  This  glass  is  jjlaced  on  a  convenient 
support,  as  a  stand  or  table,  so  that  it  will  receive  the  sun's  rays 
upon  its  surface.  A  cone  of  light  may  thus  be  reflected  to 
a  distant  point  of  the  apartment,  say  against  a  wall,  and  the 
patient  be  then  seated  so  that  his  mouth  will  intercept  the  cone. 
The  pharynx  will  then  be  brilliantly  illuminated,  and  the  ex- 
amination can  be  proceeded  with  as  already  described.  As  the 
day  advances  the  position  of  the  patient  will  have  to  be  altered 
in  compliance  with  the  track  of  the  sun. 

Sometimes  a  plane  mirror,  attached  to  the  forehead  of  the 
observer,  is  used  as  a  reflector  of  direct  solar  light. 

More  frequently  and  more  conveniently  a  concave  mirror  is 


LAEYNGOSCOPY. 


29 


used  to  reflect  the  diffuse  daylight  of  the  apartment.  This  is 
the  lar^mgoscopic  reflector,  devised  by  Czermak.  It  consists 
of  a  concave  mirror  of  circnlar  form,  abont  three  and  a  half 
inches  in  diameter,  with  a  focus  suited  to  the  visual  power  of 
the  observer.  A  focus  of  from  eight  to  twelve  inches  can  be 
used  by  the  majority  of  persons ;  but  occasionally  a  reflector 
must  be  made  especially  to  suit  the  focal  distance  of  the  ob- 
server's vision.  In  employing  this  reflector  the  ]3atient  sits  so 
that  the  light  is  towards  his  back  or  to  one  side,  and  the  observ- 
er sits  opposite  to  him,  with  the  reflector  in  his  hand,  or  upon  a 
stand  at  his  side,  or  attached  in  some  manner  to  his  forehead. 
Under  any  circumstance  the  mirror  must  be  mounted  in  such 
manner  as  to  be  susceptible  of  receiving  any  degree  of  inclina- 
tion or  obliquity.  The  light  is  then  received  upon  the  reflector, 
and  thence  reflected  into  the  mouth,  upon  the  spot  to  be  occu- 
pied by  the  laryngoscopic  mirror. 

The  accompanying  drawing  exhibits  this  mode  of  examination. 


Examination  by  reflected  light,  with  reflector  on  forehead  (from  Bennet). 

Examination  by  Artificial  Light. — In  employing  artificial 
illumination,  we  may  use  either  direct  or  reflected  light.  The 
former  method  is  the  favorite  one  in  France  ;  the  latter  generally 
preferred  in  Germany,  Great  Britain,  and  the  United  States. 


30  EXAMIlSrATION    OF    THE    THROAT. 

The  best  liglit  to  use  is  that  of  gas,  or  coal  oil.  Coal  oil 
furnishes  the  whiter  and  more  constant  light ;  gas  is  the  more 
convenient  in  management. 

In  order  to  concentrate  the  power  of  the  light  it  is  customary 
to  place  a  condensing  lens  in  front  of  it.  In  examining  by  direct 
light,  the  lamp,  w^ith  the  lens  in  front  of  it,  is  placed  upon  a 
small  stand  or  table  behind  which  the  observer  sits.  A  shade 
behind  the  light  protects  his  eyes  from  its  direct  glare.  The 
patient  is  seated  directly  in  front  of  the  light,  whi(;h  is  placed 
at  such  a  height  as  to  cast  its  rays  straight  into  his  mouth.  The 
examiner  then  passes  his  arm  around  on  one  side  of  the  lamp 
and  makes  the  examination  as  by  solar  light.  This  is  a  very 
good  method,  requiring  but  little  apparatus ;  but  it  is  rather 
awkward,  in  consequence  of  the  light  being  between  patient 
and  observer,  and  because  its  direction  cannot  be  changed 
without  suspending  the  examination.  It  is  far  inferior  in  con- 
venience to  examination  by  reflected  light,  though,  perhaps, 
occasionally  more  advantageous  in  affording  a  brighter  illumi- 
nation. 

In  examining  by  reflected  light,  we  place  the  lamp  most  con- 
veniently to  one  side  (usually  the  right  side)  of  the  patient,  a 
little  behind  his  head  and  about  the  level  of  his  ear ;  or  we  may 
place  the  light  directly  behind  and  above  the  patient's  head. 
Then  sitting  in  front  of  him  we  receive  the  rays  of  light  upon  a 
concave  reflector,  having  one-half  the  focal  distance  of  that 
with  which  we  work  by  sunlight.  Under  these  circumstances  we 
use  the  disc  of  light  just  within  or  just  beyond  the  inverted 
image  of  the  flame  as  the  illuminating  medium,  and  it  affords 
but  a  small  extent  of  luminosity.  By  placing  a  condensing  lens 
in  front  of  the  light,  we  collect  its  rays  and  obtain  a  large  cir- 
cle of  illumination  to  cast  into  the  mouth. 

The  best  illuminating  apparatus  3'et  devised  for  laryngosco 
pic  examination  is  that  of  Tobold,  as  depicted  in  Fig.  12. 

We  transcribe  essentially  Dr.  Beard's  translation  of  Tobold's 
description  of  this  illuminating  apparatus. 

"  Two  powerful  convex  glasses  {c  and  d)  of  equal  refraction 
are  fastened  in  a  brass  tube,  one  befoi-e  the  other,  close  to  the 
cylinder  of  a  lamp.     A  ring  separates  them  one  line  apart,  so 


LARYNGOSCOPY. 


31 


that  the  surfaces  of  the  glass  do  not  rub  together.  A  third 
lens  {g),  of  three-fourths  as  great  refraction,  but  of  larger  aper- 
ture, forms  the  point  of  exit  for  the  converging  rajs.  The  appa- 
i-atus  can  be  adapted  to  any  ordinary  sliding  lamp.  To  secure 
the  most  intense  light,  we  must  take  care  that  the  inner  lens  (c) 
should  be  brought  close  to  the  cylinder  of  the  lamp,  by  means 
of  the  moTable  bar  (J>).  It  is  evident  that  the  apparatus  should  be 


Fig.  13. 


Tobold's  apparatus  for  artificial  illumination  (after  Tobold). 

60  arranged  that  the  middle  of  the  flame  should  fall  as  accurate- 
ly as  possible  in  the  axis  of  the  lens.  This  axis  is  indicated  in 
the  cut  by  a  horizontal  dotted  line. 

"  The  movable  doubly  articulating  arm  {m)  is  always  fastened 
beneath  the  oil-holder  of  the  lamp.i  When  it  is  necessary  to 
clean  the  lenses  (c*)  and  {d)  the  a].)paratus  is  unscrewed  at  {/). 
The  large  outer  lens  {g)  can  be  taken  out  for  the  same  purpose, 
after  removing  the  ring  {h). 

The  concave  reflecting  mirror  (*'),  7^-  centimetres  in  diameter, 


^  We  have  found  it  more  convenient  to  place  this  arm  above  the  source  of 
illumination,  allowing  the  reflector  to  hang  down  in  front  of  the  apparatus. 


32  EXAMIISTATIOIS'    OF    THE    THEOAT. 

is  made  of  glass,  covered  with  pure  galvanicallj  j)recipitated  sil- 
ver, and  is  fastened  in  metal.  It  is  perforated  in  the  centre,  and 
is  provided  with  a  stem  of  about  10  centimetres  in  length,  so 
that  by  means  of  the  screw  (-s-)  it  can  be  moved  up  or  down  to 
the  desired  position.  The  inclination  backwards  or  forwards, 
occasionally  necessary,  is  accomplished  by  means  of  a  simple 
hinge,  (o)  on  its  border.  A  lateral  inclination  of  the  reflector  is 
entirely  unnecessary,  since  this  position  can  be  readily  secured 
by  the  movable  arm. 

"  To  those  physicians  who  have  to  examine  a  great  number  of 
patients  daily  in  the  office,  I  recommend  the  use  of  a  stand 
for  holding  the  lamj),  as  is  shown  in  the  accompanying  cut, 
Fig.  13.  By  this  arrangement  an  appropriate  position  of  the 
whole  apparatus  can  be  secured  at  any  instant  during  an  opera- 
tion by  easy  manipulation,  without  laying  aside  the  instruments 
that  are  in  the  hand.  A  rod  (E)  runs  through  an  iron  clamp,  (F) 
that  is  fastened  to  the  table,  and  by  means  of  a  screw,  {g)  can  be 
fixed  at  any  height  corresponding  to  the  size  of  the  j)atient. 
The  metallic  horizontal  arm  (H),  on  a  movable  ring  on  the  stand, 
holds  a  short  movable  rod  (^\,  on  which  the  lamp  and  its  accom- 
j)anying  brass  tube  is  attached  and  screwed,  as  on  its  usual 
support. 

"  The  rod  (X)  permits  the  lenses  to  be  adjusted  to  the  centre 
of  the  flame. 

"  The  arm  (K),  with  three  joints,  turns  directly  on  the 
frame  (-s-)." 

The  source  of  light  here  represented  is  in  each  instance  a 
coal-oil  lamp,  the  German  student  lamp,  capable  of  being  set  at 
any  elevation  upon  the  support,  and  of  being  changed  at  will. 

In  using  this  apparatus  the  flame  should  be  placed  about  on 
a  level  with  the  patient's  mouth,  but  not  near  enough  to  incom- 
mode him  by  the  heat. 

A  more  convenient  method  of  using  this  aj)paratus  is  to  take 
the  support  from  the  floor,  and  to  have  the  reflector  suspended 
above  the  lenses,  as  shown  in  Fig.  14.  This  keeps  the  supporting 
rod  out  of  the  way  of  the  left  hand  when  operating  upon  the 
larynx. 

The  apparatus  was  originally  arranged  in  this  way  by  the 


LAEYNGOSCOPY. 


33 


writer  for  his  own  use,  the  source  of  light  being  an  argand  gas- 
burner  fed  from  a  convenient  bracket  by  means  of  flexible  tub- 


Fig.  13. 


Tobold's  apparatus  for  illumination,  with  stand  (after  Tobold). 

ing.  This  adaptation  of  the  Tobold  lamp  leaves  little  to  be  de- 
sired. The  entire  illuminating  apparatus,  light,  lenses,  and  re- 
flector, being  attached  to  a  rod  movable  in  the  socket  of  the  sup- 
porting stand,  can  be  adjusted  readily  at  any  height,  and  turned 
in  any  direction  without  moving  each  portion  separately  as  in 
the  original  apparatus. 
3 


34 


EXAMINATION    OF    THE    THROAT. 


Pig.  14. 


Almost  all  the  reflectors  furnished  by  the  instrument-makers 
are  perforated  in  the  centre.      This  arises  from  the  fact  that 

Czermak  took  the  idea  of  the 
laryngoscopic  reflector  from 
that  of  the  ophthalmoscopic 
one.  It  is  occasionally  advan- 
tageous to  make  ^^se  of  the  per- 
foration, so  as  to  look  in  the 
very  axis  of  the  rays  of  light. 
The  perforation  is  by  no  means 
essential.  The  reflectors  at- 
tached to  the  head  are  some- 
times suspended  before  one 
eye.  In  that  case  they  must 
be  perforated.  A  band,  pad 
and  spring,  or  a  spectacle 
frame,  is  the  usual  means  of 
attaching  the  reflector  to  the 
head.  The  most  convenient 
method  is  to  use  a  head-band 
of  elastic  webbing. 

In  employing  artificial  light 
we  must  shut  out  any  excess 
of  daj'light.  A  dark  shade  be- 
fore the  window  suftices.  It  is 
unnecessary  to  exclude  the 
sunlight  so  much  as  to  render 
it  difficult  to  distinguish  ob- 
jects about  the  room. 

The  ingenuity  of   Dr.  To- 

Tobold's   lUuminating  Apparatus,   fed  with  gas,    bold  led  him  tO  dcS'isC  a  Small 
supported  from  floor,  with  arm  of  reflector  above  t      j_     -n  •        i  /tt         -i  k\ 

the  lenses,  the  whole  movable  up  or  down,  right  pOCkct  llUunmatOr  (I  ]g.  15), 
or  left,  by  means  of  a  supporting  rod,  sUding  in  for  traUSpOl'tatioU  tO  tllC  rcsi- 
the  socket  of  the  stand.  ■,  p  .  ,  i        i 

dence  or  patients ;  the  larger 
one  being  rather  cumbersome  for  this  purpose.  It  is  con- 
structed on  the  same  principles  as  the  larger  instrument,  and 
gives  just  as  good  an  illumination,  only  the  disc  of  light  is 
smaller.     It  is  arranged  for  attachment  to  the  student  lamp,  as 


AUT0-LAEYNG08C0PY. 


35 


seen  in  the  illustration,  but  can  be  very  readily  adjusted  to  a 
gas  jet.  With  this  instrument  I  have  been  able  to  perform  very 
delicate  operations  within  the  larynx,  such  as  cauterization,  the 
extraction  of  polyps,  local  applications  of  electricity,  etc. 


Fig.  15. 


Examination  of  the  Larjnx  by  mean?  of  Tobold's  Pocket  Illummator.     (After  Tobold.) 

Auto-Laryngoscopy — Examination  of  one's  OTvn  larynx. 

— It  is  highly  necessary  for  those  who  determine  to  attain  con- 
siderable skill  in  the  practice  of  laryngoscopy,  to  acquire  the 
facility  of  examining  their  own  laryngeal  parts.  This  is  not  so 
much  an  aid  in  learning  how  to  manipulate  upon  patients,  as 
represented  in  many  articles  on  the  subject;  for,  whatever 
method  may  be  employed,  the  movement  required  to  introduce 
an  instrument  into  one's  own  throat  is  entirely  different  from  that 
employed  in  inserting  it  into  the  throat  of  another ;  besides  which, 
we  shall  rarely  encounter  a  patient  who  will  have  control  over  his 
head,  or  over  his  laryngeal  and  pharyngeal  structures,  equal  to 
that  acquired  by  an  auto-laryngoscopist.  It  is  rarely,  too,  that 
one  will  be  able  to  demonstrate  readily  upon  a  patient  all  that  he 
can  observe  in  his  own  person ;  for  the  patient  has  not  the  prac- 
tice of  the  auto-laryngoscopist,  nor  the  same  interest  in  it ;  while, 
in  addition,  his  organs  are  seldom  in  a  state  of  comjDlete  norma- 
lism,  or  he  would  have  no  occasion  to  consult  the  practitioner. 


36  EXAMIJSTATIOTir    OF    THE    THE  OAT. 

Many  auto-larjngoscopists  have  acquired  the  power  of  exhib- 
iting their  larjmges  and  contents  to  a  wonderful  extent.  By 
reason  of  continued  practice,  the  involuntary  muscles  move  in- 
tuitively in  obedience  to  the  will,  while  the  operator  as  intuitively 
retracts  his  neck  or  elongates  it,  and  performs  various  other 
movements  which  would  be  absolutely  impossible  in  a  patient 
without  long  training.  He  who  would  attain  skill  in  examina- 
tion of  patients  must  therefore  commence  at  once  upon  a  second 
person,  as  soon  as  he  has  mastered  the  regional  anatomy  of  the 
parts  concerned,  and  has  had  some  preliminary  practice  on  the 
cadaver,  a  model,  or  an  excised  larynx  enclosed  in  a  box,  or  at- 
tached to  a  skull.  Two  or  more  individuals  studying  this  art 
together  can  alternate  for  each  other  as  patient  and  physician. 

But  auto-laryngoscopy  is  of  immense  value  to  the  science  of 
the  subject,  in  enabling  us  to  observe  the  effects,  natural  and 
acquired,  upon  the  organs  depicted,  of  various  normal  and  ab- 
normal physiological  efforts,  such  as  variations  in  respiration, 
intonation,  vocalization,  and  cantation;  the  phenomena  of  sigh- 
ing, coughing,  retching,  and  deglutition,  etc.,  as  well  as  the 
study  of  the  muscular  movements  necessary  to  bring  into 
clearer  view  any  particular  portion  of  structure.  For  such  in- 
vestigation the  inquirer  will  find  no  more  submissive  patient 
than  himself. 

Several  modes  of  auto-laryngoscopy  may  be  adopted.  The 
mode  usually  employed  by  the  writer  is  to  take  the  seat  ordi- 
narily occuj)ied  by  the  patient,  and  holding  a  hand-mirror  so 
that  its  margin  shall  be  either  below  the  reflector  or  at  one  side 
of  it,  to  direct  the  light  into  his  mouth  and  introduce  the  mirror 
with  the  disengaged  hand,  when  the  image  is  at  once  seen  in  the 
hand-mirror.  This  method  is  simple  and  convenient  for  a  mere 
examination ;  but  if  it  is  desired  to  introduce  an  instrument  into 
one's  own  larpix,  it  would  be  necessary  to  liave  the  looking-glass 
supported  in  the  proper  position,  so  that'  both  hands  could  be 
employed  with  instruments.  In  this  way  three  or  four  persons, 
standing  in  front  of  the  auto-laryngoscopist,  behind  the  miiTor 
in  his  hand,  can  look  past  it  at  the  image  in  the  laryngeal  mir- 
ror, while  those  standing  behind  him  will  see  the  image  with 
him  in  the  hand-mirror.     Of  course  it  will  be  understood  with- 


AUTO-LAEYNGOSCOPY.  37 

out  explanation  that  the  differing  angles  of  reflection  and  vision 
will  prevent  all  the  observers  from  seeing  precisely  the  same 
image.  Attention  is  called  to  the  fact  that,  notwithstanding 
the  laryngeal  image  receives  in  auto-laryngoscopy  a  second 
reflection  before  it  can  meet  the  eye  of  the  observer,  and  on  that 
account  must  be  somewhat  less  distinct  than  the  image  observed 
in  the  laryngoscopic  mirror  itself,  the  auto-laryngoscopist  does  not 
use  the  perforation  of  his  reflector;  but  this  is  placed  a  consi- 
derable distance  in  front  of  him,  and  the  light  by  which  the 
image  is  conducted  to  his  eye  is  first  reflected  upon  the  hand- 
glass fi'om  the  laryngeal  mirror,  not  only  at  quite  a  distance 
from  his  eye,  but  totally  removed  from  direct  vision  and  hidden 
deep  in  the  cavity  of  the  mouth.  This  is  a  strong  ocular  de- 
monstration that  there  is  no  necessity  for  a  perforated  reflector. 
With  a  perforated  reflector  before  liis  eye  in  this  method  of 
auto-laryngoscopy,  the  observer  could  not  obtain  a  distinct  vieAv 
of  the  image  at  all.  With  the  light  at  the  side  of  the  mirror  in 
which  the  observer  is  to  see  the  image  of  his  own  larynx,  so  that 
its  rays  fall  upon  a  reflector  attached  to  the  head,  there  is  some 
difference,  but  he  will  find  looking  through  the  perforation 
satisfactorily  an  exceedingly  difficult  matter. 

The  method  of  auto-laryngoscopy  practised  by  Czermak  is  as 
follows :  The  refieetor  is  placed  upon  a  stand  eighteen  or  twenty 
inches  in  front  of  the  observer's  mouth.  A  quadrilateral  mir- 
ror, also  mounted  on  a  stand,  is  placed  a  foot  nearer,  but  in  such 
a  manner  that  its  upper  edge  is  about  level  with  the  lower  edge 
of  the  refieetor  behind  (Fig.  16).  The  fiame  of  the  lamp  having 
been  placed  near  the  quadrilateral  mirror,  the  observer  throws  the 
light  into  his  mouth  with  the  refieetor,  and,  having  introduced 
the  laryngeal  mirror,  sees  the  image  in  the  quadrilateral  one. 
Previous  to  his  adaptation  of  the  ophthalmoscopic  refieetor, 
Czermak  performed  auto-larjmgoscopy  by  direct  light  in  front 
of  the  mouth,  holding  a  plane  mirror  in  such  way  that  the  light 
should  pass  beneath  the  mirror  and  between  the  hands  into  the 
pharynx. 

With  sunlight  the  auto-laryngoscopy  can  be  made  with  the 
reflector  or  without  it,  according  to  circumstances  or  conveni- 
ence. 


38 


EXAMINATION    OF    THE    THEOAT. 


An  ingenious  method  of  auto-laryngoscopy,  teaching  the  ob- 
server at  the  same  time  the  proper  management  of  the  light 
and  of  the  frontal  reflector  in  the  examination  of  patients,  has 


Fig.  16. 


Czermak's  auto-larj'ngoscopic  apparatus  (after  Czermak). 

been  introduced  by  Dr.  George  Johnson.  His  own  description, 
copied  from  the  London  Lancet  for  August,  1864,  is  as  follows : 
"  One  of  the  most  useful  means  of  acquiring  skill  and  confi- 
dence in  the  examination  of  the  lai-^mx  is  the  practice  of  auto- 
laryngoscopy — that  is,  the  examination  of  one's  own  larynx. 
Yarious  methods  of  auto-laryngoscopy  have  been  proposed  and 
practised.  The  simplest  and  most  satisfactoiy  plan  is  one  which 
is  very  easy  of  execution,  and  which  requires  no  special  appa- 
ratus.   The  concave  reflector  on  the  forehead,  and  the  laryngeal 


AUTO-LAEYNGOSCOPT.  39 

mirror  which  is  used  in  the  examination  of  others,  with  a  com- 
mon looking-glass  and  a  lamp,  constitute  the  whole  of  the  appa- 
ratus.  The  method  of  operating  is  this :  Sitting  at  a  table  of 
convenient  height,  I  place  a  looking-glass  at  a  distance  of  about 
eighteen  inches  in  front  of  me,  and  a  moderator  or  gas-lamp  on 
one  side  of  the  glass,  but  two  or  tliree  inches  further  back,  so 
that  the  light  may  not  pass  directl}-  from  the  lamp  to  the  mirror. 
Now,  with  the  reflector  on  my  forehead,  I  direct  the  mirror,  as 
it  were,  into  the  open  mouth  of  my  own  image  in  the  looking- 
glass;  then  introducing  the  laryngeal  mirror  into  my  mouth,  I 
see  the  reflection  of  my  larjmx  and  trachea  in  the  glass  before 
me,  and  any  one  looking  over  my  head  or  shoulder  can  see  the 
image  at  the  same  time.  This  method,  therefore,  serves  for 
auto-laryngoscopy  and  for  demonstration;  in  other  words,  the 
experimenter  can,  by  this  means,  see  his  own  larynx  and  show 
it  to  others. 

"  This  method  certainly  possesses  some  advantage  over  that 
employed  by  Czermak.  In  the  first  place,  Czermak's  plan 
requires  a  special  apparatus,  which  is  too  complicated  and  costly 
to  allow  of  its  coming  into  general  use.  Although  I  possess 
Czermak's  instrument  for  auto-laryngoscopy,  I  have  quite  ceased 
to  use  it,  because  I  find  the  other  plan  easier  and  more  satis- 
factory. I  find,  for  instance,  while  I  am  holding  the  laryngeal 
mirror  with  my  right  hand,  and  changing  the  position  of  my 
head  so  as  to  obtain  different  views  of  the  larynx,  I  can  with 
the  greatest  readiness  make  any  required  change  in  the  direc- 
tion of  the  light  by  adjusting  the  frontal  reflector  with  my  left 
hand.  This  adjustment  of  the  light  cannot  so  readily  be  made 
with  Czermak's  apparatus,  on  account  of  the  distance  at  which 
the  reflector  is  fixed  on  a  brass  stem  oj^posite  the  experimenter. 

"  For  begiimers  in  the  art  of  laryngoscopy,  this  method  affords 
a  very  useful  means  of  training  and  practice.  One  of  the  chief 
difiiculties  at  first  is  to  keep  a  steady  light  in  the  patient's 
mouth  while  the  laryngeal  mirror  is  being  introduced.  ]^ow 
the  student,  after  arranging  his  looking-glass  and  his  lamp,  may 
direct  the  light  from  the  frontal  reflector  into  his  own  open 
mouth  in  the  looking-glass.  This  process  differs  scarcely  at  all 
from  that  which  he  will  have  to  practise  on  his  patients.     Then, 


40  EXAMINATIOiq^    OF    THE    THEOAT. 

haying  learned  to  keep  the  light  steady,  he  may  practise  the  in- 
troduction of  the  faucial  mirror,  and  he  will  soon  see  the  inte- 
rior of  his  own  larynx  and  trachea.  I  have  seen  several  of  my 
medical  friends  and  pupils  succeed  in  doing  all  this  within  less 
than  half  an  hour  of  their  first  attempt. 

"  It  is  important  to  observe  that,  in  practising  this  method  of 
auto-laryngoscopy,  both  eyes  may  be  protected  from  the  glare 
of  the  lamp.  The  lamp  is  most  constantly  placed  by  the  side 
of  the  glass  to  the  left  of  the  opei-ator.  The  right  eye  is  then 
shaded  by  the  lower  margin  of  the  reflector  on  the  forehead, 
and  the  left  eye  may  readily  be  shaded  by  one  or  two  fingers 
of  the  left  hand  placed  at  the  edge  of  the  reflector.  The  fingers 
thus  placed  serve  at  once  as  a  shade  for  the  left  eye,  and  a 
means  of  moving  the  reflector  when  the  direction  of  the  light 
has  to  be  changed.  If  the  experimenter  desires  to  show  his 
larynx  to  several  persons  at  once,  he  can  readily  do  this  by 
having  the  mirror  in  front  of  him  of  small  size,  about  three 
inches  square,  and  fixed  at  a  convenient  height ;  the  small  flat 
mirror  belonging  to  Czermak's  auto-laryngoscopic  apparatus 
may  be  used  for  this  purpose.  Thus,  while  two  or  three  persons 
standing  behind  him  can  see  the  reflection  of  his  larynx  in  the 
glass,  two  or  three  others  standing  in  front  of  him,  and  looking 
over  the  top  and  by  the  sides  of  the  glass  into  his  mouth,  may 
see  the  direct  reflection  of  the  larynx  from  the  faucial  mirror." 

It  must  be  remembered  that  in  this  method  of  Dr.  Johnson 
the  image  is  not  quite  as  distinct  as  in  the  other  methods  de- 
scribed, because  the  rays  of  light  do  not  pass  to  the  laryngosco- 
pic  mirror  directly  from  the  reflector,  but  are  reflected  from  the 
looking-glass  in  which  the  image  is  seen,  and  uj)on  which  the 
light  is  directed  by  the  reflector. 

Demonstro-Laryngoseopy. — The  Exhibition  of  a  Pa- 
tient's Larynx  to  others. — The  examiner  has  frequently 
occasion  to  exhibit  the  condition  of  a  patient's  larynx  to  one  or 
more  persons,  either  for  purjDOses  of  consultation  or  for  those  of 
demonstration.  This  is  demonstrative  laryngoscopy,  and  has 
been  termed  by  Dr.  Morell  Mackenzie,  of  London,  recipro-laryn- 
goscopy.     It  is  often  quite  difficult  of  satisfactory  execution. 


DEMONSTEO-LARYNGOSCOPY.  41 

A  second  person — and  the  difficnlty  is  obvionsly  increased  as 
the  number  of  observers  becomes  more  numerous — in  order  to 
see  the  image  which  the  first  observer  is  examining,  must  look 
by  the  side  of  the  observer's  head,  or  over  his  shoulder ;  conse- 
quently, his  angle  of  vision  being  different,  he  cannot  see  the 
relations  of  the  image  exactly  as  they  are  being  described  to 
him  ;  and  the  operator,  in  moving  his  own  head  a  little  aside 
in  order  to  afford  this  second  observer  a  better  view,  can  hardly 
avoid  changing  the  position  of  the  mirror  a  little,  and  it  will 
then  reflect  parts  which  are  not  being  designedly  demonstrated, 
while  other  parts  of  the  structures  will  be  entirely  beyond  the 
field  of  reflection. 

To  overcome  this  difiiculty,  and  learn  how  to  manage  the 
mirror  and  one's  head,  so  that  those  about  the  observer  can  be 
enabled  to  see  distinctly  the  image  of  any  particular  portion  of 
the  parts  which  it  is  desired  to  demonstrate,  recpiires  a  great 
deal  of  practice,  and  often,  in  addition,  peculiar  capabilities ; 
for,  owing  to  a  law  of  physics,  from  the  narration  of  which,  to 
borrow  the  expressive  phrase  of  Semeleder,  "  we  will  spare  the 
reader,"  the  second  observer  cannot  simultaneously  with  the 
demonstrator  see  the  whole  of  the  image  which  is  being  ex- 
plained to  him. 

It  must  also  be  remembered  in  making  a  laryngoscopic 
demonstration  that,  as  with  the  beginner's  early  use  of  the 
microscope,  persons  unaccustomed  to  the  employment  of  the 
laryngoscope,  and  not  sufiiciently  familiar  with  the  regional 
anatomy  of  the  larynx  so  as  to  know  the  character  of  normal 
image  that  should  be  perceived  in  the  different  portions  of  the 
mirror,  will  fail  to  recognize  all  that  is  pointed  out  to  them, 
although  it  may  be  distinctly  visible.  Experience  in  viewing 
laryngeal  images  is  therefore  highly  necessary  before  abnormal 
alterations  and  pathological  conditions  can  be  detected. 

Demonstro-laryngoscopy  rarely  affords  as  satisfactory  a  de- 
monstration as  auto-laryngoscopy,  because  the  larynx  of  a 
patient  cannot  be  brought  under  that  amount  of  control  which 
the  auto-laryngoscopist's  self-interest  prompts  him  to  acquire; 
besides  which,  in  a  patient,  the  normal  relations  of  the  part 
may  have  become  so  altered  by  disease  as  to  render  a  satisfac- 


42  EXAMINATION    OF    THE    THROAT. 

tory  •demonstration  impossible  to  those  themselves  unable  to 
handle  the  laryngoscopic  mirror  with  the  skill  of  an  expert. 

The  writer  finds  placing  a  hand-mirror  in  tlie  grasp  of  a 
patient  a  good  method  of  demonstro-laryngoscopy  ;  and  also 
placing  a  toilet-mirror  by  his  own  side  at  the  proper  height. 
Then,  several  individuals  standing  behind  the  patient,  can  see  the 
image  he  himself  sees  in  the  mirror  in  his  hand,  while  others, 
looking  past  his  head  or  over  his  shoulders,  can  see  the  image  in 
the  toilet-mirror.  In  the  office  of  the  writer,  the  examining 
table  is  placed  directly  in  front  of  a  book-case  in  whose  doors 
are  panelled  mirrors.  The  observer  sitting  in  front  of  these 
mirrors,  his  back  towards  them,  the  examination  is  conducted  in 
the  method  previously  described,  and  several  standing  at  either 
side  of  him  see  the  direct  image,  while  a  number  standing  be- 
hind the  patient  see  the  reflected  operation  in  the  mirrors  of  the 
book-case  ;  in  viewing  which,  the  parts  being  twice  reflected, 
are  not  seen  reversed  as  in  viewing  the  direct  image.  If,  in 
addition,  a  mirror  is  placed  by  the  patient's  side,  and  another  in 
his  hand,  a  still  larger  class  can  witness  the  same  demonstration. 
In  addition  to  all  this,  if  one  of  a  third  party  of  two,  three,  or 
four,  standing  on  the  left  side  of  the  patient,  at  whose  right  is 
stationed  the  illuminating  apparatus,  take  in  his  hand  a  large 
laryngoscopic  mirror  and  hold  it  obliquely  before  the  patient's 
mouth,  on  his  right  side,  in  such  way  that  it  receives  light  re- 
flected fi'om  the  laryngoscopic  mirror  within  the  mouth,  he  too, 
and  two  or  three  at  his  side,  can  see  the  laryngeal  image  distinctly, 
without  interfering  with  the  other  observers.  In  this  way  a  de- 
monstration can  be  made  at  the  same  time  to  quite  a  large  class. 
The  extra-laryngoscopic  mirror  intended  to  be  held  obliquely 
in  front  of  the  patient's  mouth  may  be  permanently  attached  to 
the  illuminating  apparatus  by  means  of  a  little  arm  similar  to 
the  attachment  of  Tobold's  reflector.  As  this  mirror,  too,  will 
become  dimmed  by  the  halitus  of  the  breath  when  held  quite 
near  the  mouth,  it  must  be  heated  or  otherwise  prepared,  to  pre- 
vent condensation  of  moisture  on  its  surface.  When  held  by  the 
hand  from  the  opposite  side,  the  stem  must  be  placed  undermost, 
so  that  it  be  out  of  the  way  of  the  first  laryngoscopic  mirror, 
and  beneath  it  when  the  latter  has  been  passed  to  the  pharynx. 


INFRA-GLOTTIC    LAEYNGOSCOPY.  43 

To  a  teacher  of  laryngoscopy,  the  employment  of  the  second 
laryngoscopic  mirror  in  this  way  will  enable  him  to  watch  and 
direct  the  movements  of  a  pupil  much  more  accurately  and 
satisfactorily  than  by  any  other  method  with  which  the  writer 
is  acquainted ;  while  at  the  same  time  he  will  see  a  similar  image 
to  that  which  is  being  examined  in  the  mirror  in  the  mouth,  and 
be  entirely  out  of  the  way  of  the  operator's  movements. 

Dr.  Smyly,  of  Dublin,  has  contriyed  an  apparatus  for  demon- 
strating to  others  the  larynx  of  a  j^atient.  He  uses  one  of 
Weiss's  frontal  bands  to  which  is  attached  by  a  split  tube  a  per- 
forated reflector  that  is  placed  over  one  eye.  Attached  by  a 
second  split  tube  to  a  brass  rod  bent  at  an  angle  of  45°  is  a 
small  square  plane  glass  mirror  set  in  brass,  that  is  placed  in 
f  nmt  of  the  other  eye  ;  and  those  observers  standing  behind  the 
patient  see  the  reflected  image  in  this  square  mirror.  This 
apparatus  is  somewhat  clumsy  and  awkward  for  the  operator, 
necessitating  considerable  familiarity  with  its  use  for  its  satis- 
factory employment. 

Infra-Glottic  Liaryngoscopy,  or  Tracheoscopy.  —  Tra- 
cheal Laryngoscopy. — Examination  through  a  Avound  in 
the  Trachea  or  liaTynx.— Dr.  Xeiidorfer  {Wiener  Zeitschi'ift 
fur  jprakt.  HeilJcunde,  Xov.  12,  1858)  was  the  first  to  conceive 
the  idea  of  examining  the  laryngeal  and  tracheal  structures 
by  means  of  a  mirror  passed  through  the  wound  left  after  laryn- 
gotomy  or  tracheotomy,  and  demonstrated  its  possibility  on  the 
cadaver.  Fortune  very  appropriately  favored  Czermak,  the 
great  promoter  of  this  whole  art,  who  soon  after,  earh^  in  1859, 
proved  the  practicability  of  this  method  of  examination  upon 
the  person  of  a  living  patient.  Yon  Bruns,  of  Tubingen,  fol- 
lowed in  March  of  the  same  year,  since  which  time  the  records 
of  many  cases  have  been  published. 

In  this  manner  the  deeper  structures  of  the  trachea  can  be 
more  minutely  explored,  and  inspection  be  obtained  of  the 
lower  surface  of  the  vocal  cords— an  examination  otherwise  im- 
practicable. This  method  is,  of  course,  of  very  limited  applica- 
tion, from  paucity  of  subjects ;  but  in  the  laryngeal  or  tracheal 
troubles  of  patients  whose  parts  have  been  opened,  it  affords  an. 


44 


EXAMINATION    OF    THE    THROAT. 


addition  to  our  means  of  diagnosis  of  which  we  are  bound  to 
avail  ourselves.  It  very  often  happens  that  pathological  changes 
following  suicidal  wounds,  or  the  operation  of  tracheotomy  or 
laryngotomy,  will  prevent  by  tumefaction,  or  contraction  from 
cicatrization,  the  possibility  of  obtaining  a  good  view  into  the 
parts  from  above,  and  consequently  prevent  a  strictly  local  a])- 
plication  to  any  desired  spot.  Under  such  circumstances  we 
have  the  advantage  presented  of  being  enabled  to  introduce 
instruments  under  sight,  through  the  external  opening. 

The  presence  of  the  ordinary  curved  tracheotomy  tube  will 
prevent  this  examination.  The  introduction  of  a  canule  with  a 
long  f enestrum  in  its  upper  surface  will  permit  the  introduction 
of  a  mirror  ;  or  a  short,  plain,  straight  tube  may  be  employed  ; 
or  the  edges  of  the  wound  may  be  kept  apart  by  a  two-leaved 
ear  speculum,  or  by  hooks  attached  to  a  ribbon  passing  round 
the  back  of  the  neck  from  one  side  to  the  other.  The  best  mir- 
rors for  an  examination  of  this  kind  are  those  made  of  thin 
plates  of  polished  steel ;  because,  as  they  are  necessarily  exceed- 


Totold's  perforated  canula,  and  Email  metallic  mirror  for  infra-glottic  larj-ngoscopy  (after  Tobold). 

ingly  small,  we  thereby  avoid  the  loss  of  reflecting  surface 
which  would  be  caused  by  even  a  narrow  setting.  The  shape 
of  the  mirror  may  be  round  or  oval.  The  stem  of  the  mirror 
must  curve  strongly  downwards  from  its  reflecting  surface,  so 
that  when  introduced  within  the  tube,  the  handle  will  be  con- 
siderably below  the  opening  in  the  structures.  Fig.  17  repre- 
sents Tobold's  appliances  for  infra-glottic  laryngoscopy.    The  best 


INFEA-GLOTTIC    LAEYNGOSCOPY.  45 

results  are  obtained  bj  direct  sunliglit ;  and  when  artificial  light 
is  employed  it  must  be  reflected  horizontally  through  the  axis  of 
the  wound  to  the  posterior  wall  of  the  tube.  As  the  mirror 
dims  much  more  quickly  than  when  held  in  the  pharjiix,  and 
heating  it  in  the  ordinary  mode  would  necessite  its  almost 
momentary  removal,  it  is  best  to  protect  its  surface  by  sjjreadino- 
over  it  a  delicate  layer  of  gum-water,  sugar  and  water,  glycer- 
ine, or  dissolved  caoutchouc.  It  must  be  expected  to  find  res- 
piraticm  impeded  by  the  presence  of  the  mirror  in  the  respira- 
tory tube.  There  is  great  irritability  of  the  structures  fi-om  the 
contact  of  a  foreign  body,  which  renders  the  operation  by  no 
means  an  easy  one;  besides  which,  difficulties  will  often  be 
encountered  from  pathological  changes  which  may  have  fol- 
lowed the  surgical  operation. 

In  this  manner  we  can  examine  the  lower  surface  of  the  true 
vocal  cords  ;  the  posterior  wall  of  the  larynx  and  trachea  ;  the 
lower  attachment  of  the  epiglottis,  and  its  laryngeal  surface  from 
the  point  of  insertion  all  the  way  to  its  free  border ;  and  the 
anterior  face  of  the  arytenoid  cartilages ; — light  being  thro^vn 
through  the  glottis,  when  opened,  clear  on  to  the  pharynx  and 
velum. 

In  the  ordinary  laryngoscopic  examination  we  see  the  vocal 
cords  of  a  pearly  white  color.  In  infra-glottic  laryngoscopy  we 
find  the  lower  surface  of  these  cords  to  be  reddish  in  color,  as 
is  the  whole  mucous  membrane  of  the  larynx ;  so  that  some- 
times the  cords  can  be  recognized  as  such  only  by  their  move- 
'ments. 

Dr.  Semeleder,  of  Yienna,  has  reported'  a  series  of  auto-infi-a- 
glottic  examinations  observed  by  a  medical  gentleman.  "  A 
physician  from  abroad  was  taken  sick  with  typhus,  Avhich  led  to 
perichondritis  laryngea ;  after  laryngotomy  and  the  discharge 
of  a  piece  of  necrosed  cartilage,  he  was  so  far  cured  that  he 
could  attend  to  his  business ;  but  he  was  obliged  to  wear  the 
canula  for  an  indefinite  period.  He  was  often  examined  by 
the  laryngoscopists  of  Yienna ;  but  a  view  of  the  glottis  from 
above  was  impossible,  and  even  the  apices  of  the  arytenoid  car- 

1  BMnoscopy  and  Laryngoscopy ;  Caswell's  translation,  p.  96. 


46  EXAMiisrATioisr  of  the  theoat. 

tilages  were  seen  very  imperfectly  and  with  much  difficulty, 
from  the  decided  and  unyielding  depression  of  the  epiglottis  ; 
nor  could  the  glottis  be  seen  from  below,  as  a  fold  of  oedematous 
and  inflamed  mucous  membrane  closed  up  the  window  of  the 
canula.  After  the  repeated  removal  of  small  portions,  and  f re- 
cpient  cauterizations,  it  was  finally  determined  to  leave  this  fold 
to  itself ;  after  a  M'hile  it  vanished,  and  the  glottis  could  then 
be  seen  from  below  in  its  whole  extent,  manifestly  constricted, 
but  still  quite  movable.  By  an  application  of  Czermak's  self- 
observing  apparatus,  so  that  the  cone  of  light  should  fall  above 
the  laryngeal  mirror,  it  was  possible  for  the  patient  himself  to 
examine  the  glottis  from  below.  This  patient  also  gave  occa- 
sion to  numerous  improvements  and  alterations  of  the  canula, 
so  that  it  was  adapted  to  use  in  speaking." 

GESOPHAGOSCOPY. 

It  was  very  natural  that  the  success  attending  the  examina- 
tion of  the  larynx  should  have  suggested  the  feasibility  of  ex- 
amining the  oesophagus  ;  and  attempts  have  been  made  accord- 
ingly in  this  direction,  and  with  a  certain  amount  of  success,  by 
Lewin  of  Berlin,  Semeleder  of  Yieima,  Yoltolini  of  Breslau, 
AValdenberg,^  aild  others. 

There  are  great  anatomical  obstacles  to  the  performance  of 
cesophagoscopy.  The  larynx  and  trachea,  being  cartilaginous 
in  structure,  are  open  tubes ;  the  oesophagns,  on  the  contrary, 
is  a  flaccid  tube,  opened  only  when  an  object  is  presented  for  en- 
trance ;  and  in  making  a  laryngoscopic  examination,  its  opening, 
or  rather  place  of  opening,  is  seen  in  the  laryngoscopic  mirror  as 
a  transverse  groove  or  furrow  beneath  the  arytenoid  cartilages  at 
the  place  of  junction  of  the  cricoid.  In  addition  to  the  laryn- 
goscopic mirror,  it  becomes  therefore  necessary  to  dilate  the  tube 
with  a  speculum  or  appropriate  forceps,  an  operation  at  once 
snggestiA^e  of  complication  and  difficulty.  The  best  description 
of  this  manipulation  is  that  of  Semeleder,^  who  has  not  only  prac- 
tised it  upon  patients,  but  has  also  made  a  series  of  instructive 


'  Berlin.  Klin.  Woch..^  vii.  48;  Schmidfs  Jah7'b.,  cxlix. ,  p.  214. 
"  Rhinoscopy  and  Laryngoscopy  ;  Caswell's  translation,  p.  97. 


EEGIO]?^AL    AISrATO]\[Y  OF   THE    LAEYISTX.  47 

experiments  upon  himself  in  the  presence  of  distinguished 
larjngoscopists,  for  the  purpose  of  demonstrating  the  yahie  of 
the  operation  and  studying  it  thoroughly.  It  is  said  to  be  per- 
fectly feasible,  after  more  or  less  eifort,  to  explore  an  inch  or 
two  of  the  oesophagns  ;  and  one  or  two  cases  are  on  record  in 
which,  examination  being  made  after  inserting  a  stomach-tube 
of  proper  dimensions,  light  was  thrown  down  its  entire  extent, 
so  as  to  reveal  the  condition  at  the  cardiac  orifice  of  the 
stomach.     The  author  has  had  no  experience  in  this  manoeuvre. 

REGIONAL    ANATOMY    OF    THE  LAEYNX. 

Before  entering  upon  the  detailed  study  of  the  image  per- 
ceived in  the  laryngeal  mirror,  it  will  be  advisable  to  advert  iji 
succinct  terms  to  the  regional  anatomy  of  the  component  struc- 
tures, in  order  that  the  subsequent  elucidation  be  rendered  more 
satisfactory  and  comprehensive. 

The  trachea  is  surmounted  by  a  stout  ring-shaped  cartilage, 
the  cricoid,  which  may  be  viewed  as  the  base  supporting  the 
laryngeal  fabric.  Articulated  at  its  sides  by  capsular  liga- 
ments with  the  lower  horns  of  the  thyroid,  it  is  clasped  as  it 
were  by  that  cartilage,  to  the  lower  border  of  w^iich  it  is 
further  attached  anteriorly  by  a  peculiar  elastic  membrane — 
part  of  the  vocal  membrane  here  forming  the  middle  crico- 
thyroid ligament^and  laterallyby  ordinary  ligament,  and  mus- 
cle. Surmounting  the  cricoid  behind,  and  articulated  to  it  by 
loose  capsular  ligaments,  are  two  three-sided  pyramidal  carti- 
lages, the  arytenoids,  separated  from  each  other  by  a  fissure 
known  as  the  inter-arytenoid  incisure.  On  top  of  these  aryte- 
noids, and  serving  to  prolong  them  inwards  and  backwards,  are 
the  cartilages  of  Santorini,  and  at  the  side  of  their  articulation, 
occasionally  (Luschka),  a  sesamoid  cartilage.  Directly  opposite 
the  arytenoids,  and  attached  by  ligament  to  the  inner  surface 
of  the  upper  portion  of  the  angle  formed  by  the  junction  of 
the  wings  of  the  thyroid  (the  inner  surface  of  the  pomum 
Adami),  there  is  suspended  a  leaf -like  cartilage,  the  epiglottis, 
overlooking  the  entrance  into  the  larynx  like  a  trap-door, 
which  it  is.  The  greater  extent  of  this  cartilage  anteriorly  is 
closely  connected  by  ligament  from  below  upwards,  to  the  thy- 


48  EXAMINATIOIN    OF   THE   THROAT. 

roid  cartilage,  the  hyoid  bone,  and  to  the  root  of  the  tongue, 
above  the  base  of  which  its  free  broad  extremity  projects. 
From  each  side  of  this  epiglottis  as  it  tapers  down  to  its  pedicle 
of  attachment  to  the  rentrant  angle  of  the  thyroid  in  which  it 
is  confined,  there  stretches  an  elastic  membranous  structure, 
continuous  with  the  middle  crico-thyroid  ligament  and  covered 
by  mucous  membrane,  and  which,  ensheathing  in  its  course 
various  ligaments,  muscles,  and  cartilages,  is  attached  behind 
to  the  arytenoid  of  that  side,  and  below  to  the  superior  border 
of  the  side  of  the  cricoid ;  presenting,  therefore,  an  expanded 
unattached  surface  exteriorly  and  interiorly,  and  leaving  a  free 
space  or  pouch  between  its  outer  surface  and  the  inner  face  of 
each  wing  of  the  thyroid.  This  free  guttered  space,  continuous 
with  the  pharynx,  which  slopes  down  to  the  entrance  into  the 
oesophagus,  has  much  the  shape  of  a  long  three-sided  pyramid, 
the  base  above,  the  apex  below,  one  face  behind  and  the  angle 
in  front,  and  from  its  shape  is  known  as  the  pyramidal  or 
pyriform  sinus  ;  anatomically,  the  laryngo-pharyngeal  or  lateral 
pharyngeal  sulcus,  sinus,  or  fossa. 

This  membranous  expansion  on  each  side,  with  the  epiglottis 
in  front,  and  the  arytenoid  and  the  supra-arytenoid  cartilages, 
with  their  connecting  muscle  and  mucous  membrane,  con- 
stitutes the  encircling  boundary  of  the  upper  laryngeal  cavity  ; 
so  that  from  one  thyroid  plate  to  the  other  there  are  three  dis- 
tinct spaces,  the  central  one  being  the  entrance  proper  into  the 
larynx,  and  each  lateral  one  a  pyriform  sinus  tapering  down  to 
the  oesophagus.  All  that  portion  of  this  elastic  mucous  mem- 
brane above  the  middle  crico-thyroid  ligament,  being  irregular- 
ly quadrilateral  in  shape,  is  called  the  quadrangular  mem- 
brane, and  its  superior  margin  is  known  as  the  aryteno- 
epiglottic  (or,  for  short,  ary-epiglottic)  fold,  which  is  considered 
by  some  anatomists  to  consist  at  least  in  part  of  ligament 
tissue.  Near  its  attachment  to  the  apex  of  the  arytenoid 
cartilage,  this  fold  encloses  a  small  elongated  staff-like  cartila- 
ginous nodule,  the  cuneiform  cartilage  or  cartilage  of  Wrisberg, 
rudimental  and  occasionally  absent  in  the  white,  larger  and 
said  to  be  constant  in  the  negro. 

Thus    the    superior    aperture    of     the    larynx    presents    a 


REGIOlSrAL   ANATOMY  OF    THE    LAEYNX.  49 

cordiform  outline  descending  an  inclined  plane,  wide  in  fi-ont 
and  sloping  obliquely  downwards,  backwards,  and  inwards,  to 
terminate  in  the  narrow  fissure  separating  the  two  arytenoid 
cartilages. 

In  the  interior  of  the  larynx,  the  elastic  membrane  with  its 
mucous  covering,  as  it  reaches  the  petiolus  of  the  epiglottis, 
makes  an  attachment  on  each  side,  in  front  to  the  rentrant 
angle  of  the  thyroid  and  behind  to  a  tubercle  on  the  anterior 
and  iimer  face  of  the  arytenoid ;  then  rolls  outwards  on  itself 
its  whole  length  from  one  j)oint  of  attachment  to  the  other, 
forming  a  thick  fold  with  crescentic  margin  ;  which  is  the  ven- 
trioula?'  hand,  ^  and  constitutes  the  roof  of  the  ventricle  of  the 
larynx.  This  duplicature  is  continued  up  anteriorly  into  a 
pouch  or  sac  existing  between  the  two  reflected  laj^ers  of  the 
quadrangular  membrane,  running  up  often  as  high  as  the 
superior  border  of  the  thyroid  cartilage  and  sometimes  higher, 
becoming  conical  and  turning  backwards  in  the  form  of  a 
Phrygian  casque,  as  graphically  described  by  Cruveilhier ;  and 
then,  descending  the  opposite  wall  of  the  sac,  passes  the  reflected 
border  which  is  called  the  ventricular  band,  and  immediately 
below  this  point  is  reflected  horizontally  inwards  over  the 
narrow  inferior  thyro-arytenoid  ligament  or  true  vocal  cord,  a 
stout  fibrous  band  extending  from  the  rentrant  angle  of  the 
thyroid  where  it  coalesces  as  it  were  into  a  cartilaginous  prom- 
inence, the  anterior  vocal  process,  just  below  the  point  of 
attachment  of  the  ventricular  band,  to  be  attached  behind  in 
coalescence  with  a  similar  cartilaginous  protrusion,  the  poste- 
rior vocal  process,  to  the  anterior  angle  of  the  base  of  the 
arytenoid  cartilage ;  then  the  elastic  membrane  on  the  inferior 
face  of  this  true  vocal  cord  is  continuous  with  the  middle 
crico-thyroid  ligament;  after  which  the  mucous  membrane 
continues  its  descent,  and  courses  down  the  windpipe,  etc. 

Thus  there  is  formed  on  each  side  in  the  interior  of  the 
larynx,  about  half  an  inch  below  its  superior  border,  a  narrow 


^  I  would  prefer  to  substitute  for  the  objectionable  terms  true  and  false 
cords  the  phrases  ventricular  folds  and  vocal  laminm^  as  more  descriptively  sug- 
gestive. 

4: 


50  EXAMIISTATION    OF    THE    THROAT. 

elliptical  space  separating  the  true  and  false  vocal  cords.  This 
is  the  Tentricle  of  Morgagni  or  of  Galen,  and  is  the  vestibule 
of  communication  between  the  laryngeal  pouch  and  the  main 
cavity  of  the  larynx. 

The  existence  of  the  elastic  memhrcme  of  the  laryiix,  or 
vocal  membrane  as  it  is  now  more  appropriately  termed,  and 
which  determines  the  configuration  of  the  vocal  apparatus,  was 
first  described  by  Lauth  in  1835,  and  his  desci-iption  was  subse- 
quently confirmed  by  the  dissections  of  Tourtual,  Merkel, 
Luschha,  and  others.  Its  existence  was  independently  discov- 
ered in  this  countr}"  by  Dr.  Leidy,  Prof,  of  Anatomy  in  the 
University  of  Penn.,  who  in  1848  made  it  the  subject  of  an 
article  published  in  the  Americmi  Journal  of  the  Medical 
Sciences.  The  membrane  can  be  distinctly  traced  continuous 
with  the  middle  crico-thyroid  ligament  along  the  inferior 
surface  of  the  true  vocal  cord ;  but  above  this  point  it  becomes 
very  attenuated  and  is  traced  with  difficulty. 

The  articulation  of  the  lower  horns  of  the  thyroid  to  the 
sides  of  the  cricoid  permits  a  certain  amount  of  movement  on 
its  horizontal  axis.  The  ball  and  socket  articulation  of  the 
arytenoids  upon  the  cricoid  permits  verj"  free  movement  for- 
wards and  backwards,  outwards  and  inwards,  and  to  a  certain 
extent  r<:)tarily.  These  arytenoidal  movements  can  be  beauti- 
fully demonstrated  by  means  of  the  laryngoscope,  and  the  vocal 
cords,  being  attached  to  these  cartilages,  participate  in  their 
movements. 

exa:mixatiox  of  the  laet:n'geal  esiage  rx  detah.. 

The  most  prominent  structure  attracting  attention  in  the 
laryngeal  image  will  be  the  epiglottis,  whose  free  portion  pro- 
jecting stiifiy  forwards  fi'om  behind  the  liase  of  the  tongue 
renders  it  readily  recognized.  In  the  upper  j^art  of  tlie  inirror 
and  behind,  we  recognize  the  under  surface  of  the  posterior 
palatine  arches  terminating  in  the  lateral  walls  of  the  pharynx ; 
and  in  front  of  the  tonsil,  the  anterior  palatine  arches  terminat- 
ing in  the  sides  of  the  base  of  the  tongue,  of  whose  posterior 
surface  with  its  papillae,  more  or  less  is  visilde  according  to  the 
oblirpiity  of  the  miiTor.     Directing  our  attention    to  the  epi- 


THE    LAEYIs^GEAL   IMAGE.  51 

glottis  we  recognize  an  anterior  and  posterior  snrface,  and  an 
npper  arching  crest,  freqnently  indented,  continuing  down  in 
lateral  borders  from  which  is  given  off  on  either  side  a  pharyn- 
go-epiglottic  fold  of  mucous  membrane  arching  upw^ards  and 
forwards  to  join  the  posterior  palatine  arch  as  it  terminates  in 
the  lateral  pharyngeal  wall.  As  this  fold  leaves  the  epiglottis 
we  distinguish  another  fold  leaving  the  same  point  at  nearly 
right  angles  and  stretcliing  curvilinearly  backwards  to  the' 
arytenoid  cartilages.  This  is  the  ary-epiglottic  fold  forming 
the  superior  fi-ee  border  of  the  quadrangular  membrane  of  the 
larynx.  The  anterior  surface  of  the  projecting  portion  of  the 
epiglottis  is  seen  to  be  slightly  concave  from  above  downwards, 
and  strongly  convex  from  side  to  side ;  while  its  posterior  sur- 
face is  concave  and  convex  in  the  opposite  directions.  As  we 
gain  a  more  complete  and  extended  view  of  this  posterior  or 
laryngeal  face  of  the  epiglottis  we  notice  that  it  swells  out 
more  or  less  abruptly  into  a  considerable  belly  or  pad,  wdiich 
tapers  down  to  its  point  of  attachment,  and  which,  in  the  pro- 
cess of  swallowing,  etc.,  becomes  pressed  down,  like  the  pad  of 
a  truss,  upon  the  ventricular  bands.  This  is  the  tubercle  of  the 
epiglottis,  inelegantly  termed  the  "  cushion  of  the  epiglottis," 
and  is  formed  chiefly  by  an  aggregation  of  small  glands  and 
adipose  tissue.  It  \erj  often  projects  sufficiently  to  cut  off  the 
view  of  the  anterior  portions  of  the  vocal  cords  attached  to  the 
thyi'oidal  junction  below. 

From  the  anterior  and  lingual  face  of  the  epiglottis,  directly 
■in  the  middle  line,  is  stretched  a  small  sharp  bordered  mem- 
branous fold  continued  to  tlie  base  of  the  tongue,  joining  the 
raphe  of  that  organ  as  tliough  the  two  might  be  continuous. 
This  is  the  glosso-epiglottic  fold,  or  posterior  frsenum  of  the 
tongue,  or  f rjenum  of  the  epiglottis ;  and  it  encloses  the  glosso- 
epiglottic  ligament,  the  bridle  rein  forcing  the  epiglottis  to 
participate  in  the  movements  of  the  tongue.  Some  muscular 
fibres  from  the  tongue  can  sometimes  be  traced  in  this  fraenum, 
which  in  some  lower  animals  encloses  a  pair  of  muscles.  To 
each  side  of  this  fold,  which  is  strongly  raised  when  the  tongue 
is  thrust  forcibly  forwards,  there  is  seen  an  indentation,  some- 
times shallow,  oftener  deeply  depressed,  presenting  in  shape 


52  EXAMIISTATION    OF    THE    THROAT. 

and  size  very  much  such,  an  appearance  as  would  remain  mould- 
ed in  plastic  material  after  moderate  pressure  from  the  tip  of 
the  finger.  These  are  the  lingual  sinuses,  the  glosso-epiglottic 
fossse  or  sinuses,  the  vallecnlse  of  Tourtual.  When  shallow 
they  gradually  become  lost  in  the  lateral  border  of  the  tongue, 
but  more  frequently  they  are  strongly  depressed  at  the  f rsenal  out- 
line, and  becoming  less  deeply  marked  to  either  side  are  bounded 
exteriorly  by  a  sharp  fold  of  the  mucous  membrane  of  the  side  of 
the  tongue,  then  called  the  lateral  glosso-epiglottic  fold.  These 
lateral  folds  enclose  no  ligament,  and  though  generally  described 
as  existing  post-mortem,  are  very  frequently  absent  in  the  living 
organ  (first  laryngoscopically  demonsti'ated  by  Merkel) ;  and  it 
is  affirmed  by  Luschka  that  when  existing  they  join  the  sides 
of  the  pharynx,  an  anterior  leaflet  only  being  continuous  with 
the  mucous  membrane  of  the  tongue.  As  first  stated  by  Yon 
Bruns,  in  the  floor  of  these  sinuses  we  are  sometimes  able  with 
the  laryngoscope  to  discern  the  position  of  the  root  of  the 
greater  horn  of  the  hyoid  bone,  which  appears  as  a  clear  long- 
ish  oval  projection  behind  and  stretching  outwards.  These 
lingual  sinuses  often  afford  lodgments  for  articles  of  food,  pins, 
tacks,  and  other  foreign  bodies,  and  are  very  frequently  at- 
tacked by  disease.  Dr.  Horace  Green,  of  New  York,  expressed 
the  opinion  that  tuberculous  degeneration  often  commences  here, 
and  Lewin  of  Berlin  has  reported  cases  of  scrofulous  degenera- 
tion and  syphilitic  ulceration  of  these  sinuses.  Dr.  Elsberg  of 
New  York,  and  others  have  placed  on  record  cases  in  which  long- 
continued  throat  disease  had  resisted  topical  applications  to  the 
larynx,  disease  which  the  laryngoscope  revealed  to  be  ulceration 
of  these  sinuses,  soon  healed  by  intelligent  local  treatment. 

The  height  of  the  projecting  portion  of  the  epiglottis  will  be 
found  to  vary,  with  the  size,  age,  and  sex  of  the  individual, 
from  three  or  four  lines  to  an  inch,  the  average  in  the  adult 
male  being  rather  more  than  half  an  inch;  and  when  erect, 
part  of  its  laryngeal  face  will  often  curl  over  and  present  out- 
wards. Its  color  is  a  light  red  veiling  a  yellowish  white,  being 
less  pronounced  at  its  edge  where  the  color  of  the  cartilage  is 
more  distinct,  much  like  the  color  of  the  conjunctival  membrane 
of  the  eyelid,  to  which  it  was  likened  by  Stork.     Posteriorly 


THE    LAEYNGEAL   IMAGE.  53 

the  red  deepens ;  and  the  pad  appears  quite  red.  By  artificial 
light  the  parts  will  have  a  deeper  color  than  by  sunlight,  which 
must  be  borne  in  mind  lest  the  diagnosis  of  congestion  be 
improperly  pronounced.  The  tliickness  of  the  epiglottis  will 
vary  fi-om  a  sharp  thin  edge,  hardly  a  line,  to  a  thick  stump  of 
several  lines ;  and  when  swollen  it  may  be  as  thick  as  the  finger. 
It  is  very  variable,  too,  in  shape ;  sometimes  it  is  long,  narrow,  and 
pointed ;  sometimes  very  broad  and  short ;  sometimes  very  little 
curled ;  sometimes  the  sides  roll  in  together  posteriorly  until 
they  nearly  touch  ;  sometimes  it  is  curled  inwards  with  a  contrac- 
tion in  the  middle,  which  Tiirck  has  likened  to  the  sides  of  a 
jew's-harp.  All  this  must  be  remembered,  or  congenital  irreg- 
ularities may  be  diagnosed  as  alterations  in  form.  Usually  it 
is  quite  stiff ;  sometimes  it  is  flaccid.  It  is  sometimes  quite  erect, 
meeting  the  plane  of  the  tongue  at  a  right  angle ;  sometimes  its 
lingual  face  will  be  pressed  back  upon  the  base  of  the  tongue ; 
ordinarily  it  will  be  found  to  overlook  the  laryngeal  entrance 
at  an  angle  of  from  40°  to  60°,  but  it  is  sometimes  much  more 
depressed  backwards,  so  that  it  may  shut  off  a  view  into  the 
lai'ynx — and  all  this  congenitally.  AVhen  the  tongue  remains 
at  rest  upon  the  floor  of  the  mouth  or  is  only  slightly  protru- 
ded, its  base  presses  the  epiglottis  over  the  laryngeal  aperture, 
and  then  the  free  upper  border  of  the  cartilage  will  usually 
appear  as  a  narrow  band  or  stripe  more  or  less  arclied. 

The  posterior  wall  of  the  pharynx  appears  be^'ond  the  laryn- 
geal structures  in  the  lower  portion  of  the  mirror,  as  a  smootli 
glistening  surface,  sometimes  striated  in  appearance,  of  an 
ashy-red  color,  and  presenting  here  and  there  small  rounded  or 
oval  elevations,  which  are  enlarged  follicles;  and  in  some 
positions  of  the  mirror  it  can  be  seen  its  entire  length,  so  that 
in  the  lowest  part  of  the  mirror  and  behind,  about  the  position 
of  the  cricoid  cartilage,  we  observe  the  posterior  mucous  sur- 
face of  the  larynx  closely  applied  to  the  mucous  membrane  of 
the  pharynx,  affording  no  distinctive  evidence  of  the  opening 
into  the  cesophagus,  other  than  a  slightly  arched  transverse  fur- 
row marking,  by  a  dark  line,  its  point  of  commencement. 

Outside  the  ary -epiglottic  fold,  between  it  and  the  inner  face 
of  the  thyroid,  we  see  the  triangular  jpyramidal  sinus,  which 


Dtt 


EXAMIJSTATIOISr    OF    THE    THKOAT. 


Fig.  18. 


.begins  on  each  side  of  the  free  border  of  the  ej)iglottis  as  a 
small,  dark,  steep  fossa,  becoming  more  and  more  conical  as  it 
descends,  until  it  is  finally  lost  at  one  end  of  the  transverse  fur- 
row marking  the  commencement  of  the  cesophagus.  The  wall 
is  defined  to  the  outer  side  by  the  inner  face  of  the  plate  of  the 
thyroid,  and  above  this  the  hyo-thyroid  membrane  and  the 
hyoid  bone ;  to  the  inner  side,  by  the  quadrangular  membrane, 
which  forms  a  vertical  angle  anteriorly  with  the  wing  of  the 
thyroid  ;  and  behind,  it  is  bounded  by  the  posterior  wall  of  the 
pharynx.  It  is  lined  b}^  the  common  pharyngeal  mucous  mem- 
brane, and  along  its  angular  floor  there  is  a  chain  of  glands 
frequently  involved  in  disease  of  these  parts.  These  pyram- 
idal sinuses  are  sometimes  seen  entirely  clean,  sometimes 
they  contain  mucus,  and  sometimes  appear  to  contain  a  cheesy 
deposit ;  and  they  are  frequently  involved  in  pharyngeal 
troubles. 

When  the  epiglottis  is  well  raised  (Fig.  18),  we  gain  a  view  of 
the  whole  circumference  of  the  superior 
laryngeal  aperture.  This  is  triangular, 
somewhat  cordiform,  wider  in  front 
than  behind,  sloping  down  obliquely 
backwards,  and  terminating  behind  in 
the  vertical  inter-arytenoidal  fissure. 
Its  border  is  formed  in  front  by  the  free 
rim  of  the  epiglottis ;  then,  on  either 
side,  by  the  ary-epiglottic  fold,  which 
arches  backwards  in  the  form  of  a  bow 
until  it  reaches  its  arytenoidal  attach- 
ment posteriorly,  where  it  surrounds  a  rounded  eminence,  the 
cartilage  of  Santorini  •  and  the  two  arytenoids,  with  their  con- 
necting muscle  and  miicous  fold,  complete  the  border  behind. 
An  enlargement  on  each  side  in  front  of  the  cartilages  of  San- 
torini, and  breaking  the  arch  of  the  ary-epiglottic  fold  into  two 
unequal  festoons,  is  produced  by  the  enclosed  extremity  of  the 
staif-like  cartilage  of  Wrisberg  surrounded  with  glands  and 
adipose  tissue. 

A  reflection  of  mucous  membrane  runs  from  one  arytenoid 
cartilage  to  the  other,  which,  during  ordinary  respiration,  can 


Normal  larynx  during  inspiration. 


THE    LAIIY]S"GEAL    IMAGE.  55 

be  distinctly  seen  forming  tlie  posterior  boundary  of  this  supe- 
rior portion  of  the  larynx ;  but  during  ^localization  the  contrac- 
tion of  the  arytenoid  muscle  approximates  tlie  cartilages,  and 
the  band  of  mucous  membrane  folds  up,  exposing  the  vertical 
fissure.  The  obliquity  of  this  border  renders  the  thyroidal  wall 
of  the  larynx  much  deeper  than  the  arytenoidal.  Dr.  Elsberg, 
of  jSTew  York,  writes,  that  in  this  posterior  wall  he  has  detected 
the  presence  of  tubercles  long  before  the  ordinary  phj^sical  signs 
of  phthisis  could  be  recognized,  and  that  after-results  verified 
this  early  prognosis.  Czermal^  Stork,  Lewin,  and  others  have 
recorded  similar  observations. 

If  we  look  down  along  the  inner  or  laryngeal  face  of  tlie  quad- 
rangular membrane,  we  will  see  on  either  side,  about  half  an 
inch  below  its  superior  border,  the  red  mucous  membrane  folding 
under  on  itself,  forming  the  ventricular  band  or  false  vocal  cord, 
a  broad  mucous  fold,  and  leaving  between  it  and  the  horizontal 
surface  of  the  true  vocal  cord,  seen  immediately  below  as  a  white, 
glistening  band  extending  fi-om  before  backwards,  an  oblong  in- 
terval, which  is  the  ventricle  of  the  larynx,  and  which  leads  up 
into  the  laryngeal  sac.  By  means  of  a  deep  inspiration,  espe- 
cially if  short,  sudden,  and  following  vocalization,  these  ventricles 
can  be  rendered  more  distinct,  and  a  separation  of  their  walls  be 
observed  dilating  the  cavity.  The  size  of  the  ventricles,  or  rather 
the  space  constituting  them,  varies.  It  is  contended  by  some 
anatomists,  that  these  ventricular  bands  are  not  merely  duplica- 
tures  of  mucous,  or  of  mucous  and  elastic  membrane,  but  that 
they  are  composed  in  part  of  ligamentous  tissue  (superior  thyro- 
arytenoid ligament)  and  some  muscular  fibre.  It  is  generally 
conceded  that  they  contain  a  delicate  narrow  band  of  fibrous  tis- 
sue continuous  with  the  fibrous  capsule  of  the  laryngeal  sac,  but 
destitute  of  muscular  fibre.  There  is  no  doubt,  however,  that 
they  occasionally  approximate  in  voluntary  contractions  of  the 
larynx  ;  I  have  sometimes  seen  them  come  close  together  and  cut 
off  the  view  of  the  vocal  cords  so  gracefully  that  it  was  almost 
impossible  to  resist  the  idea  that  the  action  was  indeed  due  to 
muscular  tissue  in  their  proper  substance.  In  the  mucous  mem- 
brane of  the  sac  there  open,  as  first  described  by  Hilton,  some 
sixty  or  more  small  follicular  glands,  situated  in  the  submucous 


06  EXAMINATIOlSr    OF    THE   THEOAT. 

connective  tissue.  Its  laryngeal  surface  is  covered  by  the  inferior 
portion  of  the  aryteno-epiglottideus  muscle  (compressor  sacculi 
laryngis  of  Hilton)  which  compresses  the  sac  and  discharges  its 
secretions  npon  the  true  vocal  cords,  which,  being  themselves 
unprovided  with  glands,  are  thus  lubricated. 

The  floor  of  the  ventricle  is  formed  by  the  true  vocal  cord, 
which  is  easily  recognized  by  its  semi-metallic  lustre — a  mother-of- 
pearly  white  in  the  female,  with  a  yellowish  dash  in  the  male ;  a 
strong,  thick,  flbrous-looking  band  (the  inferior  thyro-arytenoid). 
The  sharp  edge  of  this  band  constitutes  the  vocal  cord  par  excel- 
lence. This  structure,  at  least  its  lower  surface,  is  an  extension 
inwards  of  the  vocal  membrane,  or  the  middle  crico-thyroid  liga- 
ment. Each  cord  consists  of  a  compact  band  of  parallel  fibres  of 
elastic  and  fibrous  tissue,  arranged  in  prismatic  form,  the  base  be- 
ing outwards,  so  that  a  vertical  section  shows  the  njDper  surface 
horizontal,  and  the  lower  surface  taking  an  oblique  direction 
downwards  and  outwards.  Firmly  imbedded  into  the  external 
portion  of  the  vocal  cords  are  some  short  pennated  fibres  from  the 
vocal  muscle,  the  thyro-arytenoid,  which  is  adherent  and  parallel 
to  it,  attached  in  front  to  the  receding  angle  of  the  thyroid,  and 
behind  to  the  arytenoid.  When  the  two  true  vocal  cords  are 
approximated,  their  horizontal  surface  forms  a  floor  to  the  upper 
laryngeal  cavity.  They  form  with  the  space  between  their  free 
edges  the  glottis ;  their  sharp  borders  are  the  lij^s  of  the  glottis, 
and  the  chink  or  fissure  between  these  lips  is  the  rima  glottidis. 
These  terms  should  not  be  confounded.  The  length  of  the  rima 
in  the  male  varies  from  ten  to  thirteen  lines;  in  the  female, 
from  seven  to  ten  lines ;  in  children  it  is  much  less  :  and,  when 
dilated,  the  space  across  will  vary  ordinarily  from  three  to  six 
lines ;  but  when  widely  dilated  by  a  deep  inspiration,  it  may  be 
from  six  to  ten  lines,  leaving  a  space  large  enough  often  to 
admit  a  good-sized  finger.  The  rima  of  the  glottis  is  not  formed 
by  the  vocal  cords  alone,  but  also  by  the  inner  face  of  the  ary- 
tenoids posterior  to  the  points  of  attachment  of  the  cords ;  so 
that  we  speak  of  an  inter-ligamentous  rima  corresponding  to  the 
length  of  the  cords,  say  eight  lines,  and  an  inter-cai-tilaginous 
rima  posteriorly,  about  three  lines.  Luschka  is  disposed  to  decry 
this  division,  which  is  due  in  appearance  to  the  knuckling  in- 


THE   LARYNGEAL    I3IAGE.  57 

wards  of  the  posterior  attachments  of  the  cords  Avhen  the  pos- 
terior vocal  processes  converge  inwards. 

The  form  of  the  rima  glottidis  varies. — During  ordinary  res- 
piration it  is  a  narrow  interval  somewhat  enlarged  and  ronnded 
behind,  looking  not  unlike  the  lozenge-shaped  space  formed  by 
pressing  together  the  tips  of  the  two  thumbs  and  the  tips  of  the 
two  fore-fingers,  and  then  extending  the  thumbs  rather  strongly 
posteriorly  and  the  fingers  anteriorly,  when  the  space  separating 
the  two  thumbs  will  represent  the  inter-cartilaginous  rima,  and 
the  remaining  space  the  inter-ligament ous  rima.  When  widely 
dilated,  the  rima  acquires  the  form  of  an  equilateral  triangle, 
the  base  being  behind.  The  form  of  the  rima  varies  greatly 
during  phonation,  and  may  become  elliptical,  oval,  or  opened 
only  anteriorly,  as  the  cords  are  acted  upon  by  the  complex 
thja-o-arytenoid  muscle,  with  portions  of  which  their  structure 
is  blended,  and  by  the  contraction  of  other  muscles  attached  to 
the  arytenoids. 

When  the  epiglottis  is  well  raised  from  the  laryngeal  aper- 
ture, as  by  the  emission  of  a  high  musical  note,  so  that  the 
anterior  portions  of  the  vocal  cords  can  be  discerned,  we  often 
see  below  the  small  end  of  the  pad  of  the  epiglottis,  immediate- 
ly beneath  the  junction  of  that  cartilage  to  the  thyroid,  and 
separating  the  anterior  attachments  of  the  ventricular  bands,  a 
well-marked,  sharply-defined,  pinhead-like  pit  or  foramen  in 
the  mucous  membrane.  This  is  the  fovea  centralis  of  Merkel, 
and  communicates  directly  on  both  sides  with  the  anterior 
entrance  into  each  laryngeal  sac,  being  continuous  below  with 
a  shallow  groove  formed  by  a  short  fold  of  the  laryngeal  mucous 
membrane  which  stretches  across  from  the  anterior  end  of  one 
vocal  cord  to  the  other.  This  fovea  centralis  is  one  of  the  chief 
points  of  insertion  for  the  elastic  membrane.  Though  very  small 
in  the  human  subject,  it  is  said  to  be  quite  large  in  many  lower 
animals,  as  in  the  horse,  where  it  seems  to  constitute  a  middle 
ventricle  to  the  larynx. 

The  anterior  and  posterior  points  of  insertion  of  the  vocal 
cords  are  seen  upon  them  as  four  yellowish  spots,  the  macule 
JlavcB,  which  mark  the  positions  of  the  vocal  processes. 

The  mucous  membrane,  as  it  passes  from  one  arytenoid  carti- 


58 


EXAMIlSrATION    OF   THE    THROAT. 


lage  to  the  other,  is  thrown  into  loose  folds  known  as  the  co7)%- 
onissure  of  the  arytenoids,  and  is  best  seen  stretching  across 
when  the  arytenoids  are  sejDarated.  As  these  cartilages  ap- 
proach each  other,  this  commissure  becomes  folded  up,  as  it 
were,  within  the  vertical  cleft  or  notch,  the  arytenoid  fissure. 
often  termed  improperly  the  posterior  glottis. 

The  special  points  of  observation  are  well  represented  in  the 
accompanying  drawings,  from  Mackenzie.^ 

Fig.  20. 


Fig.  19. — Laryngosoopic  drawing,  showing  the 
vocal  cords  drawn  widely  apart,  and  the  posi- 
tion of  the  various  parts  above  and  below  the 
glottis,  during  quiet  inspiration. 
ge.  Glosso-epiglottidean  folds. 
u.  Upper  surface  of  epiglottis, 
I.  Lip  of  epiglottis, 
c.  Cushion  of  epiglottis. 
V.  Ventricle  of  larynx. 
ae.  Ary-epiglottidean  fold, 
c  W.  Cartilage  of  Wrisberg. 
cS.  Capitulum  Santorini. 
com.  Arytenoid  commissure. 
PC.  Vocal  cord. 
t)&.  Ventricular  band. 
pv.  Processus  vocalis. 
cr.  Thyroid  cartilage. 

t.  Cricoid  cartilage,  below  which  are  seen  sev- 
eral rings  of  the  trachea. 

Under  unfavorable  circumstances  the  view  is  limited  to  a 
portion  of  the  base  of  the  tongue,  the  edge  of  the  epiglottis, 
imore  or  less  of  the  arytenoid  cartilages,  and  some  portions  of 
the  posterior  wall  of  the  pharynx. 

If  we  wish  to  examine  the  whole  laryngeal  face  of  the  epi- 
glottis and  the  anterior  extremities  of  the  vocal  cords,  we  direct 
the  patient  to  sound  a  high  note  quickly  and  with  a  little  force. 


I     com   "■ 

Fig.  20. — Laryngosoopic  drawing,  showing  the 

approximation  of  the  vocal  cords,  and  the 

position  of  the  various  parts  in  the  act  of 

vocalization. 

fl.  Fossa  innoininata. 

t)f.  Hyoid  fossa.* 

ch.  Cornu  of  hyoid  bone. 

c  W.  Cartilage  of  Wrisberg. 

cS.  Capitulum  Santorini. 

a.  Arytenoid  cartUage. 

com.  Arytenoid  commissure. 

a.  Arytenoid  cartilage. 

pv.  Processus  vocalis. 

(In  reality,  during  phonation  the  vocal  cords 
are  much  closer  than  is  shown  in  the  draw- 
ing, the  posterior  vocal  processes  being  in 
contact.) 

*  Pyriform  sinus. 


'  The  Use  of  the  Laryngoscope. 


THE   LAEYNGEAL    IMAGE.  59 

which  effort  i-aises  the  larynx,  closes  the  glottis,  and  throws  the 
epiglottis  up  with  a  jerk,  so  that  the  horizontal  surface  of  the 
vocal  cords  is  distinctly  seen,  as  well  as  the  ventricular  bauds  and 
the  ventricles.  An  inspiration  accompanied  by  sound,  or  an 
ironical  laugh,  will  bring  the  same  structures  in  view.  If  this 
does  not  suffice,  some  of  the  instruments  described  for  pulling 
the  epiglottis  forward  may  be  emj^loyed.  When  a  depressed 
epiglottis  prevents  a  view  of  the  cords,  Ave  may  judge  of  their 
mobility  by  the  movements  of  the  arytenoids,  which  can  almost 
alwaj^s  be  recognized. 

To  examine  the  posterior  extremities  of  the  vocal  cords,  the 
anterior  surfaces  of  the  arytenoids,  the  ar^'tenoid  commissure, 
and  the  inner  posterior  wall  beneath,  we  reflect  the  light  more 
posteriorly  by  inclining  the  mirror  towards  the  horizon  during 
an  inspiration,  which  inspiration  opens  the  glottis  and  separates 
the  arytenoids,  which  look  upwards,  backwards,  and  outwards, 
exposing  their  anterior  faces. 

To  examine  the  posterior  walls  of  the  ar^-tenoids  down  to  the 
cricoid,  and  obtain  a  good  view  into  the  pyramidal  sinuses,  we 
direct  the  emission  of  sound,  so  as  to  close  the  glottis ;  in  doing 
which,  the  arytenoids  approacli,  exposing  their  pharyngeal  sur- 
face, separating  more  widely  the  quadrangular  membranes  from 
the  plates  of  the  thyroid. 

To  obtain  a  view  farther  down  the  trachea  than  is  represented 
in  the  figures,  we  place  the  mirror  more  perpendicularly,  and 
direct  a  deep  inspiration,  so  as  to  open  the  glottis  to  its  f  idlest 
extent,  and  then,  by  a  little  manipulation,  reflecting  the  light 
more  anteriorly,  we  may  see  several  tracheal  rings  as  narrow 
bands,  colored  like  the  conjunctival  membrane  of  the  eyelid, 
arching  across  with  their  concavities  downwards,  becoming  nar- 
rower and  closer  as  they  are  more  distant,  until  the  foreshorten- 
ing is  such  that  they  cannot  be  distinctly  counted;  and  some- 
times in  this  way,  when  the  circumstances  are  favorable,  such 
as  a  good  mirror,  a  steady  hand,  a  well-directed  hght,  a  straight 
tracheal  axis,  a  wide  glottis,  etc.,  we  can  gain  a  view  clear  down 
to  the  bifurcation  of  the  tube.  Sometimes,  when  we  fail  to  ob- 
tain such  an  extended  view  with  the  light,  patient,  eye,  and 
mirror  in  the  ordinary  position,  we  can  succeed  by  elevating  the 


60  EXAMIKATION    OF   THE    THEOAT. 

position  of  the  patient  so  that  the  eye  of  the  observer  shall  be 
below  the  plane  of  the  patient's  mouth ;  then  throwing  the  light 
from  below  upon  the  laryngoscopic  mirror,  which  is  to  be  held 
horizontally,  the  light  can  be  reflected  clear  down  the  windpipe, 
and  we  can  see  most  distinctly  the  increasing  foreshortening  of  the 
tracheal  rings ;  and  if  the  bifurcation  be  yisible,  we  see  behind 
the  last  ring  (below  in  the  mirror),  instead  of  the  complete  arch 
with  its  concavity  downwards,  a  bright  triangular  space,  base 
up,  which  often  seems  to  project  up  into  the  interior  of  the 
tube,  and  on  either  side  of  this  triangular  space  dark  circular 
discs  marking  the  commencement  of  the  bronchise.  If  the  right 
bronchus  is  very  straight,  sufficient  light  can  sometimes  be 
thrown  in  to  demonstrate  more  or  less  of  its  extent. 

A  good  rule  by  which  to  hunt  for  the  view  of  the  bifurcation 
is,  to  get  a  good  view  of  the  laryngeal  face  of  the  epiglottis, 
and  then,  with  this  as  a  guide,  to  continue  inspection  along 
this  plane  right  down  the  anterior  surface  of  the  trachea, 
gradually  lessening  the  obliquity  of  the  mirror  as  we  gain  a 
deeper  view. 

If,  when  a  view  of  the  trachea  has  been  obtained,  we  turn  the 
mirror  a  little  to  one  side,  we  obtain  a  lateral  view  of  that  tube 
resembling  the  turns  of  the  thread  in  the  nut  of  a  screw\ 

THE   MUSCULAR   FORCES   PKODUCESfG    CHANGES    IN    THE  FOEM  OF   THE 

GLOTTIS. 

Before  leaving  the  demonstrative  portion  of  our  subject,  it 
will  be  advisable  to  allude  to  the  muscles  moving  the  laryngeal 
structures,  and  to  whose  contractions  are  due  the  various  altera- 
tions of  form  observed  during  the  performance  of  the  physiolo- 
gical functions  of  respiration  and  vocalization. 

In  the  first  place,  there  are  several  muscles  outside  of  the 
laryngeal  tube. 

1.  Crico-arytenoideus  posticus,  one  on  each  side,  occupies 
the  lateral  half  of  the  posterior  face  of  the  cricoid,  and  runs 
upwards  and  outwards  to  be  inserted  into  the  exterior  posterior 
part  of  the  arytenoid  surmounting  the  cricoid  on  that  side. 
Use,  to  rotate  the  arytenoid  outwards  and  backwards,  and  open 
the  chink  of  the  glottis.     This  muscle  may  be  viewed  as  the  ex- 


THE    LAKYJSTGEAL    MUSCLES.  61 

tensor  muscle  of  the  respiratory  glottis,  opening  the  intercarti- 
laginous  rima,  antagonizing  the  arytenoidens. 

2.  Orico-arytenoideus  lateralis,  one  on  each  side,  runs  from 
along  the  superior  margin  of  the  sides  of  the  cricoid,  obliquely 
npwards  and  backwards  to  the  outer  angle  of  the  base  of  the 
arytenoid,  just  in  front  of  the  insertion  of  the  posterior  crico- 
arytenoid. Une,  to  draw  the  arytenoid  forwards  and  outwards, 
turning  the  posterior  vocal  processes  inwards,  and  thus  contract- 
ing the  chink  of  the  glottis  in  vocalization. 

3.  Crico-thyroideus,  one  on  each  side ;  a  triangular  muscle 
running  from  the  anterior  lateral  surface  of  the  cricoid  upwards 
and  backwards  to  the  inferior  edge  of  the  thyroid  plate,  and  in- 
to its  inferior  horn,  leaving  an  interval  between  itself  and  fellow 
occupied  by  that  portion  of  the  vocal  membrane  called  middle 
crico-thyroid  ligament.  Use,  to  draw  the  thyroid  upon  the 
cricoid  with  a  forward  rotary  motion,  thus  stretching  the  vocal 
cords,  rendering  them  tense  and  contracting  the  chink  of  the 
glottis. 

4.  Then  we  have  behind,  the  arytenoideus,  a  single  muscle, 
sometimes  described  as  three  distinct  muscles.  A  transverse^ 
portion,  the  deepest,  goes  posteriorly  from  the  whole  length  of 
one  arytenoid  to  the  other,  covering  them  completely  excejDt  at 
the  very  tip  ;  over  this  portion  two  oblique  portions  cross  each 
other,  running  respectively  from  the  base  of  one  arytenoid  to 
the  apex  of  the  other.  Sometimes  portions  of  this  muscle  are  con- 
tinuous with  the  thyro-arytenoideus  and  the  arj^teno-epiglotti- 
deus,  one  or  both,  seeming  to  act  in  consonance  with  them  in 
closing  the  larynx.  In  fact,  there  seems  to  be  a  guttural  com- 
munication, right  over  this  muscle,  with  the  posterior  portion  of 
the  ary-epiglottic  fold,  leading  from  the  ventricle  of  Morgagni 
up  the  inner  posterior  wall  of  the  larynx  and  out  into  the 
pharynx  behind.  This  gutter  or  drain  is  thefiltrum  ventricxdi 
of  Merkel,  and  seems  intended  to  lead  off  into  the  pharynx  any 
accumulating  secretion  from  the  laryngeal  pouch. 

,  The  use  of  the  arytenoideus  is  to  bring  the  two  arytenoid 
cartilages  in  close  apposition,  which  it  does  very  completely  by 
means  of  its  transverse  and  oblique  fibres,  so  that  the  plane  sur- 
faces of  the  posterior  vocal  processes  touch  each  other  and  thus 


62  EXAMIISTATIOlSr    OF    THE    THROAT. 

close  the  posterior  portion  of  the  glottis.  This  innscle  may  be 
viewed  as  the  flexor  of  the  respiratory  glottis.  So  much  for  the 
exterior  muscles  of  the  larynx. 

In  the  interior  of  the  larynx  we  find  several  ranscular  strnc- 
tures  enclosed  within  the  cpadrangnlar  membrane.  These  are 
on  each  side : — 

1.  Thy7'o-ejnglottideii.s,  a  delicate  mnscle  running  fi-om  the 
posterior  inner  face  of  the  thyroid  near  its  rentrant  angle,  just 
outside  of  the  thyro-arytenoid,  into  the  side  of  the  epiglottis. 
Use. — To  pull  the  epiglottis  down.  This  it  can  do  ordinarily 
only  when  the  tongue  is  relaxed,  and,  for  this  reason,  the  dropping 
of  the  epiglottis  is  usually  attributed  to  backward  pressure  from 
the  base  of  the  tongue  relaxing  the  middle  glotto-epiglottic  liga- 
ment; but  it  has  been  shown  by  the  laryngoscope  that  some 
persons  can  acquire  such  control  over  their  organs  as  to  drop 
the  epiglottis  with  the  tongue  extended ;  and  this  would  seem 
to  confirm  the  ascribed  use  of  this  nmscle  as  a  true  depressor. 

2.  Aryteiio-ejnglottideus,  a  still  more  delicate  muscle,  run- 
ning from  the  superior  lateral  portion  of  the  arytenoid  into  the 
side  of  the  epiglottis,  some  of  its  fibres  being  lost  in  the  ai-y-epi- 
glottic  fold.  This  muscle  is  indistinctly  defined  horizontally 
into  what  is  sometimes  described  as  a  superior  and  an  inferior 
muscle,  the  inferior  portion  of  which  (compressor  sacculi  laryn- 
gis,  Hilton)  compresses  the  laryngeal  pouch  and  squeezes  its  se- 
cretion out  upon  the  vocal  cords.  The  superior  portion  will 
constringe  th6  upper  portion  of  the  quadrangular  membrane, 
and,  with  the  thyro-epiglottic  muscle,  assists  to  close  the  superior 
laryngeal  aperture. 

3.  The  Vocal  Muscle. — There  is  still  another  intrinsic  laryn- 
geal muscle  on  each  side  meriting  a  more  detailed  mention  than 
that  of  its  mere  origin  and  insertion.  This  is  the  thyro-aryte- 
noideus,  lying  external  to  the  vocal  cord  and  inseparably  at- 
tached to  it,  from  which  circumstance  many  anatomists  have 
considered  the  vocal  cord  but  the  tendon  of  this  muscle.  It  is 
most  usually  descril)ed  as  parallel  to  the  outer  side  of  the  cord, 
arising  from  the  lower  half  of  the  rentrant  angle  of  the  thyroid 
cartilage  and  from  the  middle  cri co-thyroid  ligament,  and  pass- 
ing: backwards  and  outwards  to  be  inserted  into  the  anterior  and 


THE    LAKTNGEAL    MUSCIES.  63 

outer  face  of  the  arytenoid  and  into  its  base ;  its  use  being  to 
relax  the  vocal  cords  and  shorten  them,  thus  lessening  the  length 
of  the  chink  of  the  glottis. 

The  thyro-arytenoid  muscle,  however,  is  quite  complex  in  the 
arrangement  of  its  fibres,  and  seems  to  be  the  vocal  muscle  par 
excellence,  to  whose  contractions  are  mainly  due  the  various 
changes  of  forms  produced  in  the  glottis  during  vocalization, 
cantation,  etc.  It  has  been  very  thoroughly  described  by  Ba- 
taille,  who  has  dissected  it  minutely,  as  consisting  of  three  dis- 
tinct portions;  for  which  reason  he  has  proposed  for  it  the  name 
trice])  s-la  ryngea . 

These  three  portions  are  called  \)y  ^2A:2c\S\j&^\,  faisceau ])lan ; 
'^,faisGeau  median  ou  arciform  /  and  3,  faisceau  jxiraholoid. 

The  three  heads  arise  in  close  propinquity  from  the  ^-entrant 
angle  of  the  thyroid.  The  first  ox  jplctin  hundle  runs  back  with 
long,  flat,  horizontal  fibres,  to  be  inserted  into  the  inferior  bor- 
der of  the  arytenoid  cartilage.  The  second  or  middle  portion 
forms  a  triangular  pyramid,  separable  into  two  flat  triangles, 
the  base  being  inserted  into  the  concave  face  of  the  arytenoid 
cartilage,  its  internal  surface  being  adherent  nearly  throughout 
to  the  first  or  flat  bundle;  and  near  its  ar^-tenoidal  attachment  it 
anastomoses  again  with  this  flat  bundle  by  short  pemiate  fibres. 
Its  superior  surface  is  concave,  and  forms  the  floor  of  the  ven- 
tricle. The  third,  hundle  assnines,  the  form  of  an  irregular  pa- 
rabola, with  fibres  divisible  into  superior,  middle,  and  inferior 
layers,  and  sends  out  fibres  of  attachment  to  the  first  and  second 
bundles,  and  also  to  the  internal  wall  of  the  ventricle.  The 
upper  edge  of  the  first  bundle  is  intimately  incorporated  into  the 
tissue  of  the  vocal  cords  by  short  pennated  fibres,  and  forms  a 
large  portion  of  the  constituent  structure  of  the  cord,  especially 
of  its  inferior  surface. 

The  above  resume  is  but  an  outline  of  the  minute  anatomy 
of  this  complex  muscle,  which  makes  still  further  attachments 
to  the  epiglottis  and  other  adjacent  parts  ;  but  it  is  sufficiently 
descriptive  to  show  its  intricate  arrangement  and  intiinate  rela- 
tions with  the  vocal  cord,  so  that  it  does  not  seem  irrational  to  infer 
that  it  has  iio  slight  participation  in  the  function  of  producing 
the  various  changes  of  form  and  tension  in  the  glottis,  by  means  of 


64  EXAMINATIOIS'    OF   THE    THROAT. 

whieli  a  narrow  band  of  tissue,  scarce  eight  lines  in  length,  and 
barely  more  than  a  line  in  breadth,  and  with  but  a  single  margin 
free  to  vibrate,  is  rendered  adequate  in  response  to  emotion,  or 
mental  conception,  to  execute  the  immense  variety  of  sound  and 
modulation  of  which  the  human  voice  is  capable.  There  is  but 
little  doubt  tliat  the  careful  study  of  the  mechanical  construc- 
tion of  this  muscle,  coupled  with  a  sufficient  number  of  accurate 
laryngoscopic  observations  as  to  the  changes  of  form  in  the 
glottis,  and  consonant  action  of  other  parts  attendant  upon  the 
production  of  musical  tones  in  the  various  registers,  will  in  time 
disclose  to  j)hysiology  many  of  the  secret  mysteries  of  the  most 
distinctive,  seductive,  and  suggestive  characteristic  of  hu- 
manity,— the  voice. 

MTJCOUS    ME:SIBRA2vE,    GLA3STDS,  ELOOD-VESSELS,    AXD    2sEKVES    OF  THE 

LAEITS'X. 

The  contour  of  the  larynx,  externally  and  internally,  is  cov- 
ered by  mucous  membrane  continuous  with  that  of  the  mouth 
and  pharynx.  It  differs  in  thickness  and  degree  of  adhesion  to 
subjacent  parts.  It  is  exceedingly  thin  and  closely  adherent  on 
the  free  borders  of  the  true  vocal  cords ;  thin,  but  less  adlierent 
in  the  sac  of  Hilton ;  loosely  adherent  to  the  ventricular  bands  ; 
thicker  and  closely  adherent  on  the  posterior  face  of  the  epiglot- 
tis, and  on  the  inner  faces  of  the  vocal  processes ;  less  adherent 
to  the  anterior  surface  of  the  epiglottis ;  very  loosely  attached 
to  the  ary-epiglottic  folds  and  to  the  arytenoidal  walls,  which 
parts  are  thus  extremely  liable  to  become  infiltrated,  so  that  the 
inner  surfaces  almost  touch,  producing  oedema  of  the  larynx,  or, 
as  it  is  improperly  termed,  oedema  of  the  glottis. 

The  epithelium  is  the  ciliated  variety  found  covering  the 
whole  mucous  respiratory  tract,  with  the  exception  o£  a  narrow 
stripe  of  the  squamous  epithelium  of  the  oesophagus,  which 
mounts  the  larynx  posteriorly,  continues  down  the  internal  face 
of  its  posterior  wall,  and  covers  the  free  portion  of  the  true 
vocal  cords  from  one  end  to  the  other.  On  the  inferior  face  of 
the  cords  the  ciliated  epithelium  is  again  encountered. 

The  larynx  is  abundantly  supplied  with  glands.  They  are 
found  in  the  laryngeal  pouches,  in  the  pyramidal  sinuses,  in  the 


HISTOLOGY    OF    THE    LAEYJfX.  65 

posterior  wall,  in  the  arj-epiglottic  folds  where  near  their  aryte- 
noidal  attachments  they  are  accumulated  in  the  form  of  an  L, 
and  are  called  collectively  the  arytenoid  glands ;  in  the  pad  of 
the  epiglottis,  and,  isolated,  elsewhere  ;  but  there  are  none  upon 
the  true  vocal  cords.  They  are  sometimes  solitary,  sometimes 
in  clusters,  and  vary  from  the  size  of  a  poppy-seed  to  that  of  a 
lentil. 

The  lar^Tix  is  supplied  with  blood  by  branches  from  the 
superior  and  inferior  laryngeal,  and  the  crico-thyroid  arteries. 

The  veins  empty  into  the  superior,  middle,  and  inferior  thy- 
roid veins. 

The  nerves  supplying  the  larynx  are  the  superior,  and  in- 
ferior or  recurrent  laryngeal  of  the  par  vagum,  with  some 
filaments  from  the  great  sympathetic.  The  inferior  laryno-eal 
is  the  motor  nerve,  and  supplies  all  the  muscles  except  the  crico- 
thyroid, which,  with  the  mucous  inembrane,  is  supplied  by  the 
superior  laryngeal,  which  also  sends  some  fibres  t(5  the  aryte- 
noideus. 

HISTOLOGY    OF    THE   LAKYNX. 

According  to  the  researches  of  Luschka,  whose  AnatoQiiie  des 
Menschen  is  the  most  elaborate  and  instructive  on  this  subject 
which  the  writer  has  consulted,  we  learn  that  the  cartilages  of 
the  larynx  are  composed  of  true  cartilage  structure — fibr(j-car- 
tilage  and  reticular  cartilage.  The  thyroid,  cricoid,  and  the 
greater  portion  of  tlie  arytenoid  cartilages  are  formed  of  or^ 
dinary  cartilage,  bluish-white  in  color.  This  form  has  consid- 
erable disposition  during  the  course  of  time  to  undergo 
pathological  degeneration.  It  undergoes  earliest  the  fibrous 
degeneration,  by  which  it  becomes  fragile,  assumes  a  vellow 
color,  or  becomes  spotted  with  yellow,  and  grates  under  the 
knife.  In  the  so-called  granular  degeneration,  it  assumes  a 
turbid  color,  sometimes  yellowish,  sometimes  the  color  of  asbes- 
tos. The  intercellular  substance  is  filled  more  or  less  with 
larger  and  smaller  dark  molecules,  and  contains  isolated  larger 
granular  bodies  distributed  through  it.  Sometimes  the  de- 
generation is  into  porous  osseous  substance  richly  supplied  with 
adipose  matter,  and  this  occurs  so  frequently  in  mature  age 
5 


66  EXAMINATION  OF  THE  THEOAT. 

that  R.  Columbus  (<7!  £.  Jforgagni,  Adversaria  Anat.  1,  23) 
does  not  hesitate  to  enumerate  the  larynx  with  the  osseous  sys- 
tem. The  ossification  occurs  most  frequently  in  the  cricoid  and 
thyroid  cartilages,  sometimes  occu.rring  earlier  in  one,  at  other 
times  in  the  other.  Segond  says  that  the  muscular  process  is 
always  the  starting-point  of  the  ossification ;  and  that  next  to 
the  influence  of  age,  the  amount  of  exercise  influences  its  de- 
generation. And  he  contends  that  this  occurs  earlier  and  in 
greater  extent  among  professional  vocalists  than  among  indi- 
viduals who  do  not  make  extraordinaiy  use  of  their  voices.  • 

Less  frequently  than  ossiflcation,  infiltration  of  carbonate  of 
lime  is  met  with,  which  is  also  said  to  occur  in  the  capsules  of 
the  cartilage  as  well  as  its  hyaline  substance. 

The  epiglottis,  the  cartilages  of  Santorini,  of  Yfrisberg,  the 
sesamoid  cartilages,  the  vocal  processes  and  points  of  the  aryte- 
noids, the  coUiculus  and  vocal  processes  of  the  thyroid  cartilage, 
are  composed  of  yellow  or  reticular  cartilage.  These  are  liable 
to  calcification  rather  than  ossification. 

The  thyroid  cartilage  is  ordinarily  described  as  composed  of 
two  plates,  alse,  or  wings,  which  are  joined  at  the  centre.  This 
is  not  sufiiciently  exact.  It  was  first  pointed  out  by  Eambaud, 
and  subsequently  by  J.  A.  Cavasse,  Halberstma  (Luschka),  et 
al.,  that  there  is  an  intermediate  or  central  cartilage  uniting  the 
two  wings — the  lamina  intermedia.  This  has  much  the  form 
of  an  inverted  wine-glass  with  fiaring  edges,  or  the  large  ex- 
tremity of  a  trumpet ;  but  occasionally  it  is  rhomboidal  in  shape. 
It  can  be  recognized  in  all  ages  and  in  both  sexes,  and  can  be 
readily  separated  in  the  unossified  larynx  after  the  perichon- 
drium has  been  fully  removed,  which  can  be  best  done  in  those 
which  have  been  immersed  for  some  time  in  alcohol.  A  ti'ans- 
verse  or  vertical  section  will  show  its  existence,  and  it  can  be 
isolated  by  maceration  in  a  dilute  solution  of  potassa.  It  is 
composed  of  a  hyaline  cartilage  structure,  and  by  its  more  gray- 
ish color  can  be  distinguished  from  the  milky-white  of  the  alse 
proper.  The  cartilage  of  this  intermediate  portion  of  the  thy- 
roid on  its  inner  surface  receives  the  anterior  vocal  processes, 
to  which  the  true  vocal  cords  are  attaclied.  It  has  been  shown 
by  Gerhardt  to  be  composed  of  reticular  cartilage,  but  it  de- 


HISTOLOGY    OF    THE    LARYISTX.  67 

parts  from  the  usual  construction  of  reticular  cartilage,  inas 
much  as  instead  of  the  usual  thickly-matted  small,  dark,  short 
elastic  fibre  arrangement,  here  paler  fibrils,  sometimes  plaited 
in  bands,  cross  each  other,  sometimes  horizontally,  sometimes 
curvilinearly,  forming  interspaces  in  which  large  cartilage-cells 
are  hei-e  and  there  distributed.  This  fibrous  cartilaginous 
structure  has  been  found  unchanged  by  Luschka,  even  when 
the  lamina  intermedia  had  become  completely  ossified,  which 
circumstance  would  seem  to  show  that  it  may  maintain  some 
important  physiological  relation  to  the  true  vocal  cords. 

We  have  spoken  of  the  yellow  color  of  the  vocal  processes 
of  the  arytenoids.  It  is  demonstrable  by  the  microscope,  as, 
was  first  pointed  out  by  Rheiner,  that  through  the  fibrous  base- 
ment structure  of  their  reticular  cartilage,  these  processes  are 
actually  continuous  with  the  fibro-elastic  element  of  the  true 
vocal  cords. 

The  sesamoid  cartilages  first  discovered  by  Luschka  are  only 
occasionally  present.  They  have  been  observed  in  various  de- 
grees of  development  in  both  sexes,  at  all  ages,  and  in  both 
feebly  and  strongly  built  individuals. 

The  vocal  cords  are  duplicatures  of  the  elastic  vocal  membrane 
of  the  larynx ;  and  their  remarkable  susceptibility  of  vibration 
is  due  to  a  peculiar  fibrous  band  which  forms  their  basement 
structure.  The  general  mucous  membrane  projects  beyond  this 
band,  enveloping  it  more  or  less  loosely  and  permitting  the  sepa- 
rate action  of  the  membrane  as  vibrating  reeds  in  the  formation 
of  the  falsetto  tones.  At  their  extremities  the  cords  are  rein- 
forced with  reticular  cartilage,  by  which  their  susceptibility  of 
vibration  is  secured,  and  their  ossification  prevented.  Their  an- 
terior and  posterior  extremities  are  so  thoroughly  connected  with 
the  anterior  and  posterior  vocal  processes  that  their  fibrous  struc- 
ture is  inextricably  blended  into  the  felt-like  elastic  element  of  the 
vocal  cords.  In  addition  to  this  a  large  proportion  of  the  fibres  of 
the  thyro-arytenoid  muscle  is  so  intimately  bound  up  into  this 
diiplicature  of  elastic  vocal  membrane,  and  so  incorporated  into 
its  structure,  that  it  actually  forms  the  largest  moiety  of  the 
body  of  the  cord. 

There  are  found  in  the  reticular  cartilage  of  the  epiglottis, 


08  EXAMiisrATioisr  of  the  theoat. 

irreo-nlar  pits  or  notches  containing  follicular  and  racemose 
glands.  This  inlaying  with  glandular  structure  gives  it  a  great 
disposition  to  ulceration,  which,  when  it  occurs,  usually  results 
in  ulcers  in-egularly  serrated  in  outline. 

The  bulging  belly  of  the  epiglottis  is  due  in  part  to  an  in- 
creased thickness  of  cartilage,  but  in  a  greater  measure  to  an 
accumulation  of  glandular  and  adipose  tissue. 

The  perichondrium  of  the  cartilages  of  the  larynx  is  com- 
posed of  thick  areolar  tissue,  interspersed  with  a  few  irregular 
elastic  fibres.  It  contains  a  tolerably  rich  network  of  blood- 
vessels. But  few  nerves  can  be  traced  in  it,  and,  according  to 
Luschka,  only  as  primitive  fibres.  According  to  J.  Eugles,  who 
has  minutely  investigated  the  structure  of  this  perichondrium, 
that  of  the  epiglottis  is  most  richly  supplied  with  nerves,  and 
upon  both  its  surfaces. 

EHINOSCOPY. 

Rhinoscopy  is  the  term  applied  by  Czermak  in  designation  of 
his  method  of  inspecting  the  posterior  region  of  the  nares  by  re- 
flected light.  It  suggested  itself  at  an  early  date  to  this  observer 
as  an  outgrowth  from  laryngoscopy,  and  he  first  described  '  it  soon 
after  his  name  had  become  familiarly  associated  with  the  sister 
art.  As  inspection  of  the  nostrils  anteriorly  is  also  rhinoscopy,  it 
would  be  as  well  to  call  the  other  method  posterior  rhinoscopy. 

Rhinoseopic  examination  of  the  naso-pharyngeal  region. 

— The  laryngoscopic  apparatus  sufiices  for  rhinoseopic  exami- 
nation. The  principles  involved  are  precisely  the  same  as  in 
laryngoscopy ;  the  only  difference  being  in  the  position  of  the 
mouth  mirror,  w^hich  is  to  be  placed  beneath  the  soft  palate  and 
uvula,  or  behind  them,  with  its  reflectiug  surface  looking  up- 
wards and  forwards,  so  as  to  direct  the  light  upon  the  posterior 
openings  of  the  nasal  passages  and  upon  the  parts  in  immediate 
proximity.  The  image  of  these  parts  is  then  seen  in  the  mirror. 
The  pharynx  is  to  be  most  strongly  illuminated  at  a  point  a  little 
lower  than  that  usually  selected  for  laryngoscopic  observation. 

'  Ueber  die  Inspektion  des  Cavum  pharyngo-nasale  und  den  Xasenhohle 
vennittelst  kleiner  Spiegel.      Wk?i.,Med.  Woch.,  Aug.  6,  ISbd. 


EHINOSCOPY.  69 

The  primary  requisite  to  a  successful  examination  is  the 
existence  of  sufficient  space  for  the  mirror  between  the  velum 
and  the  posterior  wall  of  the  pharynx.  When  the  hard  palate 
extends  unusually  far  back,  it  may  be  impossible  to  make  an 
examination  with  the  mirror,  as  happened  in  one  case  under 
the  care  of  the  author.  Such  cases,  however,  are  altogether  ex- 
ceptional. As  a  rule,  an  examination  may  almost  ahvays  be 
readily  effected,  though  seldom  with  the  facility  that  attends  a 
laryngoscopic  examination. 

It  is  essential  for  the  introduction  of  the  mirror,  that  the 
soft  palate  should  hang  free  from  the  posterior  Avail  of  the 
pharynx.  When  the  mouth  is  opened  for  purposes  of  examina- 
tion, there  is  usually  an  involuntarj'^  disposition  to  breathe  through 
it.  This  causes  the  palate  to  apply  itself  against  the  posterior 
wall  of  the  pharynx,  and  thus  shut  off  all  communication  be- 
tween the  month  and  the  nares.  If  breathing  be  performed 
through  the  nose,  the  palate  drops,  and  the  communication 
between  nose  and  mouth  is  then  free,  as  in  ordinary  respiration 
with  the  mouth  closed.  Hence  we  direct  the  patient  to  breathe 
through  his  nostrils  while  his  mouth  is  open.  This  response  of 
the  palate  to  respiration  through  mouth  or  nose,  and  its  play 
backwards  and  forwards,  can  be  readily  observed  in  a  looking- 
glass.  If  the  patient  cannot  succeed  in  maintaining  respiration 
through  the  nose,  we  may  force  his  palate  to  fall  forwards  by 
causing  him  to  emit  nasal  sounds,  such  as  the  French  en  •  and, 
as  the  respiratory  current  passes  by  the  nostrils,  the  palate  falls. 
This  plan  was  suggested  by  Czermak.  Should  this  device  fail, 
we  resort  to  forcible  separation  of  the  palate  fi-om  the  pharyn- 
geal wall  by  means  of  a  broad  and  fiat  hook  passed  under  and 
behind  the  velum,  and  then  drawn  forwards  and  upwards  by 
the  observer.  This  plan  is  often  but  partially  successful,  inas- 
much as  it  usually  induces  spasmodic  action  of  the  muscles  of 
the  palate,  the  disposition  to  which  spasm  is  to  be  overcome 
only  by  repeated  contact  of  the  instrument  until  its  presence 
and  pressure  is  tolerated,  or  until  the  irritability  of  the  muscles 
is  exhausted.  The  same  amount  of  time  and  patience  devoted 
to  the  proper  regulation  of  the  respiration  will  insure  the  suc- 
cess of  the  latter  and  more  desirable  expedient. 


70  EXAMINATION    OF   THE    TITROAT. 

The  difficulties  to  be  overcome  in  rhinoscopic  examination 
are,  with,  the  exception  of  the  respiration  just  treated  of,  the 
same  as  those  described  under  the  head  of  laryngoscopy. 

The  same  mouth  mirror  may  be  used  for  rhinoscopic  as  for 
laryngoscopic  examinations,  only  there  is  more  frequent  occa- 
sion for  the  employment  of  a  mirror  of  smaller  diameter. 
There  is  no  necessity  for  attaching  the  mirror  to  the  stem  at  a 
right  angle,  as  recommended  by  some  authors,  nor  is  such  a 
miri'or  as  conveniently  manipulated  as  the  laryngoscopic  mirror. 

If  a  vertical  position  of  the  reflecting  surface  is  desired,  it 
may  be  obtained  very  readily  by  depressing  the  handle  of  the 
mirror.  If,  on  the  other  hand,  it  be  desired  to  gain  a  view  of 
the  roof  of  the  nares,  or  of  the  vault  of  the  pharynx,  the  handle 
can  be  raised  so  as  to  give  the  inirror  a  more  oblique  position. 
A  reflection  of  the  parts,  exact  as  to  size  and  form,  such  as  we 
obtain  of  our  faces  in  a  toilet  mirror,  could  be  obtained  only  in 
the  absence  of  necessary  structures  which  prevent  our  seeing 
the  reflection  when  the  mirror  is  exactly  behind  the  nares  in  a 
vertical  plane.  It  is  only  an  image  in  perspective  of  the  parts 
in  front  of  the  mirror  and  above  it  that  can  be  seen  at  best,  and 
this  we  secure  with  the  laryngoscopic  mirror  in  rhinoscopic 
position  much  more  readily  than  with  the  so-called  rhinoscopic 
mirror. 

In  the  earlier  days  of  rhinoscopy,  it  was  thought  essential  to 
employ  some  means  of  drawing  the  palate  upwards  and  forwards ; 
and  various  palate-hooks  and  elevators  have  been  devised  for 
the  purpose.  This  want  was  probably  occasioned  by  the  use  of 
the  mirror  at  right  angles  to  its  shank.  "Wlien  such  a  contri- 
vance is  requisite,  which  occurs  only  occasionally,  a  flat  plate  of 
metal  or  hard  rubber,  three  or  four  lines  in  breadth,  terminat- 
ing in  an  edge  turned  up  for  about  one  or  two  lines,  and  fenes- 
trated or  not,  according  to  fancy,  will  be  found  serviceable. 
When  the  space  between  velum  and  pharynx  is  small,  it  may 
sometimes  be  enlarged  by  repeatedly  drawing  the  velum  for- 
wards by  means  of  a  blunt  hook,  these  manipulations  being 
repeated  at  inteiwals  for  several  days.  The  space  nva,j  also  be 
increased  by  confining  the  palate  in  two  tapes  passed  through 
the  nostrils,  out  of  the  mouth,  and  tied  over  the  upper  lip  in  front. 


EHINOSCOPY.  71 

A  sort  of  double  T  bandage  with  four  tails  answers  this  pm-pose, 
and  may  sometimes  be  employed  in  this  way  for  purposes  of  more 
thorough  examination,  or  for  facilitating  operative  procedures. 
These  contrivances  are  not  well  borne. 

The  use  of  a  tongue-depressor  is  almost  always  necessary  in  a 
rhinoscopic  examination.  It  increases  the  space  between  the 
tongue  and  the  palate,  and  gives  more  room  for  the  passage  of 
the  mirror. 

When  a  large  mirror  cannot  be  used — and  cases  are  not  infre- 
quently met  with  that  permit  the  use  of  a  mirror  an  inch  and  a 
quarter  in  diameter— small  mirrors  are  passed  first  upon  one 
side  and  then  upon  the  other,  so  as  to  examine  the  structures  of 
each  side  successively. 

Instruments  combining  tongue-depressor  and  mirror  have 
been  invented  by  several  observers,  but  they  are  altogether 
superfluous,  inasmuch  as  the  management  of  the  tongue  can  be 
entrusted  to  the  patient,  thus  affording  the  operator  a  chance  to 
employ  with  his  disengaged  hand  whatever  other  instrument 
may  be  necessary  for  treatment. 

The    Structures   Subjected  to  Rhinoscopic  Inspection 

are : — 

The  posterior  surface  of  the  soft  palate  and  the  uvula ; 

The  posterior  and  part  of  the  lateral  portions  of  the  sej)tum 
of  the  nose,  the  turbinated  bones,  and  the  nasal  meatuses  ; 

The  pharyngeal  walls  of  the  Eustachian  tube  and  its  orifice  ; 

The  vault  or  roof  of  the  pharynx  ; 

The  lateral  walls  of  the  pharynx  ;  and 

The  upper  portion  of  the  posterior  wall  of  the  pharynx. 

These  structures  cannot  all  be  examined  in  one  and  the  same 
image ;  but  by  gently  turning  the  reflecting  surface  of  the 
mirror  towards  the  different  regions  we  are  able  gradually  to 
complete  a  satisfactory  survey  of  the  whole  in  detail.  In  some  cases 
we  can  see  both  choanse,  both  Eustachian  tubes,  and  most  of  the 
vault  of  the  pharynx,  in  one  and  the  same  image.  An  image  of 
this  kind  is  represented  in  Fig.  21 ;  and  in  some  instances  we  can 
see  much  more  of  the  surfaces  of  the  turbinated  bones,  that  is, 
much  more  deeply  into  the  meatuses,  than  is  here  represented. 


72 


EXAMINATION    OF   THE    THEOAT. 


It  is  very  essential  to  become  familiarized  with  the  appear- 
ances represented  in  the  rhinoscopic  mirror  in  order  to  be  able 
to  recognize  the  individual  structures ;  not  only  because  these 
parts  are  rarely  submitted  to  dissection,  but  also  because  the 
idea  of  the  relation  of  parts,  as  seen  in  the  skull  deprived  of 
soft  tissue,  is  not  realized  in  the  examination  under  consid- 
eration. 

If  we  examine  the  image  represented  in  Fig.  21,  we  shall 

find  the  most  prominent 
Fig-  21-  object  to  be  a  bright  co- 

lumnar ridge  in  the  cen- 
tre, gradually  expanding 
above.  This  is  the  nasal 
septum.  It  is,  in  health, 
of  a  pale  yellow,  or  yel- 
lowish pink  color  at  its 
narrow  portion,  but  as  it 
expands  its  color  grad- 
ually merges  into  the  red 
of  the  pharyngeal  mucous 
membrane  above  it.  Fol- 
lowing the  outline  of  the 
expanding  portion  of  the 
septum,  we  define  upon 
each  side  the  posterior 
border  of  each  correspond- 
ing nasal  opening,  the  lowermost  portion  of  which  is  cut  off 
from  view  by  a  horizontally  curved  projecting  ridge  of  a  red 
color,  which,  with  as  much  of  it  as  is  reflected  below,  is  the 
posterior  surface  of  the  velum.  Following  the  inner  curve  of 
this  velum  round  on  either  side,  we  observe  it  rising  over  the 
outer  portion  of  each  nasal  opening,  and  forming  a  projecting 
ridge  which  is  formed  by  the  fibres  of  the  levator  palati  muscle 
forming  the  anterior  wall  of  the  pharyngeal  extremity  of  the  Eus- 
tachian tube  ;  and  we  find  it  continuous  on  the  outside  with  an- 
other projection  above,  which  is  the  cartilaginous  extremity  of  the 
Eustachian  tube;  and  between  these  two  projections  we  observe 
a  considerable  depression,  of  triangular  outline,  which  is  the 


Rhinoscopic  Image. 
1.  Vomer  or  nasal  septum.  2.  Free  space  of  nasal  pas- 
sages. 3.  Superior  meatus.  4.  Middle  meatus.  5. 
Superior  turbinated  bone.  6.  Middle  turbinated 
bone.  7.  Inferior  turbinated  bone.  8.  Phai-j-ngeal 
orifice  of  Eustachian  tube.  9.  Upper  portion  of  fossa 
of  RosenmiiUer.  11.  Glandular  tissue  at  the  anterior 
portion  of  the  vault  of  the  pharjTix.  12.  Posterior 
surface  of  the  velum. 


EHINOSCOPY. 


73 


pharyngeal  orifice  of  the  Eustachian  tube.  Following  the  pro- 
tuberance caused  by  the  Eustachian  tube  backwards,  we  observe 
it  defining  a  canal,  the  terminal  fossa  of  which,  as  it  runs  up- 
wards and  outwards,  is  the  fossa  of  Rosenmiiller,  lying  between 
this  lateral  projection  and  the  posterior  wall  of  the  pharynx. 
This  is  the  point  in  which  the  Eustachian  catheter  is  so  often 
engaged  by  mistake  during  the  use  of  that  instrument. 

Returning  to  the  central  portion  of  the  image,  the  parts  in 
shadow  on  each  side  of  the  septum  represent  the  free  cavity  of 


Fig.  29. 


Khinoscopic  image  in  a  case  of  cleft  palate. 


Case  of  cleft  palate  from  which 
rhinoscopic  image  (Fig.  22) 
was  obtained. 


the  nose  on  each  side  respectively.  Following  this  shadow  from 
below  upwards  on  either  side,  we  see  it  terminate  in  a  large 
shadow,  which  represents  the  upper  meatus  ;  the  light  jDortion 
above  this,  still  within  the  choanum,  is  the  upper  turbinated 
bone,  of  the  lower  portion  of  which  a  small  portion  is  still  fur- 
ther seen  projecting  into  the  shadow;  the  outer  portion  of  the 
upper  turbinated  bone  turns  down  and  seems  to  be  lost  in  a 
central  bulbous  portion  which  is  the  middle  turbinated  bone  ; 
this  is  partly  covered  by  another  prominent  object  which  is  the 
inferior  turbinated  bone :  and  above  this  and  to  the  outside  is  a 


74  EXAMlNATIOlSr    OF   THE    THROAT. 

shadow  representing  what  is  seen  of  the  middle  meatus.  Occa- 
sionally, but  not  in  the  image  figured,  we  can  discern  the  posi- 
tion of  the  inferior  meatus  just  beneath  the  lower  turbinated 
bone,  only  a  portion  of  which  is  seen  in  the  drawing. 

A  better  view  of  the  lower  turbinated  bones  is  obtained  in  a 
view  represented  in  Fig.  22,  and  drawn  by  Dr.  Packard  from 
one  of  the  author's  cases  of  cleft  palate,  shown  in  Fig.  23  before 
closure  of  the  fissure.  As  complete  a  view  of  these  structures 
is  occasionally  encountered  without  the  pre-existence  of  any 
defect  in  the  palate. 

In  the  instance  referred,  to  the  fissure  enabled  the  mirror  to  be 
.  placed  higher  up  than  can  ordinarily  be  done,  and  thus  secured  a 
better  view  of  the  middle  and  lower  turbinated  bones. 

p,.    24  Fig.  24  represents  a  rhinoscopic  image 

from  one  of  the  author's  cases,  in  which  an 
unusually  good  view  of  the  pharyngeal  ori- 
fice of  the  left  Eustachian  tube  is  obtained 
by  slightly  rotating  the  face  of  the  mirror 
to  that  side, 
viewof  leftEu^chianorifice.  ^hc  color  of  thc  healthy  mucous  mem- 
brane of  the  nasal  and  naso-pharyngeal 
structures,  as  seen  in  the  rhinoscopic  image,  varies  fi'om  a  pale 
grayish-red  or  yellow,  with  a  mere  tinge  of  pink,  to  a  drab  or  the 
more  decided  red  of  the  pharyngeal  mucous  membrane.  The 
narrow  column  of  the  sejDtum,  and  the  inner  or  lower  walls  of 
the  Eustachian  orifice,  are  of  a  pale  pink-3'ellow,  sometimes  de- 
cidedly yellow ;  the  projections  of  the  Eustachian  tube  are  red; 
the  superior  turbinated  bone  is  a  light  pink  ;  but  any  of  its  lower 
or  lateral  surface  that  may  be  seen  is  dark-gray ;  the  middle 
turbinated  bone  looks  gray  and  is  very  distinct ;  the  lower 
turbinated  bone  is  still  darker  and  less  distinct ;  the  sides  of 
the  septum,  when  not  diseased,  are  drab  or  ashy-red  ;  the  other 
structures  are  red,  the  reflection  of  the  velum  at  the  Eustachian 
tube  being  of  a  lighter  red  below  than  above.  The  precise  tint 
of  each  structure  varies  with  the  character  of  the  light,  its  posi- 
tion influencing  the  shadows ;  and  also  with  the  position  of  the 
patient.  The  description  attempted  above  corresponds  as  near 
as  may  be  to  the  tints  given  by  artificial  light. 


EHINOSCOPY.  75 

In  gaining  a  view  of  the  posterior  nares,  the  first  reflection 
seen  in  the  mirror  as  it  is  passed  under  the  vehim  is  the  ima2;e 
of  the  posterior  aspect  of  the  uvula,  vehim,  and  palatine  arches ; 
presenting  together,  especially  when  the  parts  are  tense,  much 
the  general  appearance  of  the  outline  of  the  image  of  the  sep- 
tum and  nasal  openings,  especially  should  one  of  the  molar  teeth 
be  reflected  just  to  the  side  of  the  uvula.  AVlien  this  image  of 
the  velum  and  arches  is  seen,  the  handle  of  the  mirror  should 
be  gradually  depressed,  or  the  reflecting  surface  be  slipped  up 
further  behind  the  velum,  when  we  will  see  the  velum  gradu- 
ally extending  itself  as  it  were,  and  then  turning  on  itself  back- 
wards at  a  right  angle,  looking  not  unlike  a  shelf  of  flesh,  on 
top  of  which,  and  somewhat  in  its  rear,  we  begin  to  recognize 
the  true  image  of  the  septum  and  nares  making  its  appearance 
in  the  mirror. 

Examination  of  the  nasal  passages  anteriorly.  —  This 
might  be  termed  anterior  rhinoscopy.  A  thorough  examination 
of  the  anterior  portion  of  the  nasal  passages  should  not  be  neg- 
lected in  cases  implicating  the  nostrils.  Yery  often  it  will  suf- 
fice for  this  purpose  to  throw  the  head  of  the  patient  back,  and 
turn  the  point  of  the  nose  up  so  as  to  get  the  parts  as  much  as 
possible  in  a  horizontal  plane,  and  with  a  good  light  upon  them. 
Keflected  daylight,  or  artificial  light,  is  often  much  better  than 
direct  sunlight,  as  we  can  direct  the  illumination  along  the 
passages  by  moving  a  reflector,  much  more  readily  than  we  can 
by  moving  the  patient's  head. 

The  nostrils  may  be  dilated  by  means  of  a  pocket  probe  or 
some  small  instrument  pressed  against  the  outer  portion  of  the 
nostril.  A  small  aural  speculum  sometimes  answers  the  pur- 
pose ;  and  it  is  pushed  back  as  far  as  the  position  of  the  nasal 
bones,  so  as  to  dilate  the  cartilaginous  portion  of  the  passage. 
A  bivahe  aural  speculum  has  been  modified  by  Mr.  Hilton,  by 
making  the  blades  longer,  broader,  and  slightly  curved.  Els- 
berg's  three-leaved  steel  dilating  speculum  (Fig.  25),  modelled 
after  the  tracheal  dilator  of  Trousseau,  answers  admirably  for 
this  purpose. 
^    An  excellent  nasal  dilator  devised  by  Thudichum  (Fig.  26) 


76 


EXAMIl^TATIOI^    OF   THE    THEOAT. 


stretches  the  nostrils  very  satisfactorily.  It 
and  then,  as  it  expands,  liolds  its  position 
If  well  borne  it  exposes  the  parts  very 
pressure  is  usually  so  painful  that  a  small 
sion  must  be  used  to  weaken  the  spring. 
adapted  for  operating  upon  the  deeper 
sizes  are  requisite  in  order  to  suit  the  nostr 

Fig.  25. 


is  introduced  closed, 
when  once  adjusted, 
effectually;  but  the 
amount  of  corapres- 
It  is  especially  well 
structures.  Several 
ils  of  the  patients. 

Pig.  S6. 


Elfiberg's  nostril  dilator  aud  speculum. 


Thudlcum's  dilating  speculum  for  the  nostrils. 


Dr.  Metz  uses  a  dilator  made  in  two  portions,  each  attached 
to  a  sejjarate  handle  ;  these  portions  may  be  used  singly  or 
together. 

Complete  satisfactory  examination  is  only  occasionally  possible, 
the  deeper  portions  of  the  structures  being  entirely  out  of  direct 
or  reflected  vision. 

In  exploring  the  nasal  passages  we  can  sometimes  iind  good 
service  in  the  use  of  the  little  finger,  previously  oiled  and  then 
employed  as  a  probe.  In  this  way  we  may  sometimes  be  en- 
abled to  determine  the  position  of  ulcers,  tumore,  foreign  bodies, 
calcareous  concretions,  etc.,  which  we  may  not  be  able  to  discover 
either  on  anterior  inspection  with  the  sj)eculum,  or  by  2:)0ste- 
rior  inspection  with  the  rhinoscope. 

In  cases  of  doubt  as  to  the  occlusion  of  the  nasal  passages, 
"Wintrich  has  suggested  an  indirect  method  of  physical  diagno- 
sis which  is  noticed  on  account  of  its  curiosity,  without  any 
comment  on  its  value.     The  tympanitic  sound  yielded  on  per- 


KIIINOSCOPY.  77 

cnssion  of  the  larynx,  lowers  in  pitch  when  one  nostril  is  closed, 
and  becomes  still  deeper  and  weaker  in  tone  when  both  nos- 
trils are  closed.  If,  now,  it  is  found  that  no  change  is  eifected 
on  the  percussion  pitch  of  the  larynx  by  closing  one  or  the  other, 
or  both  nostrils,  it  is  to  be  inferred,  says  Wintrich,  that  their 
permeability  is  occluded  by  the  presence  of  secretion,  tumor, 
or  foreign  body  in  one  or  the  other  nostril,  or  both,  as  the  case 
may  be. 


78  SOEE    THROAT. 


CHAPTER   III. 

SORE    THROAT. 

Soke  theoat  may  be  exceedingly  mild  in  character,  and  may 
vary  from  mere  annoyance  to  a  condition  of  intense  suffering 
as  exliibited  in  the  higher  grades  of  inflammation.  All  the  ana- 
tomical regions  of  the  throat  may  be  affected  together,  or  the 
disease  may  be  confined  to  one  or  more  of  them ;  and  various 
names  have  been  given  to  designate  the  special  locality  of  the 
affection.  Inasmuch,  however,  as  the  essential  disease  is  the 
same  in  nature,  produced  by  the  same  causes,  and  amenable  to 
the  same  plan  of  treatment,  it  will  be  convenient  to  consider  the 
varieties  of  sore  throat  together. 

The  name  cynanche  (from  the  Greek),  and  angina  (from  the 
Latin),  has  been  applied  to  designate  inflammations  of  the 
throat,  especially  when  accompanied  by  disturbances  m  the 
functions  of  deglutition  and  respiration.  Thus  we  have 
cynanche  jparotidcBa,  mumps,  or  parotitis ;  cynanche  tonsillaris, 
tonsillitis,  amygdalitis,  quinsy;  cynanche  j^haryngea,  pharyn- 
gitis ;  cynanche  laryngea,  acute  laryngitis ;  cynanche  trache- 
alis,  croup ;  and  we  have  cynanche  trachealis  s^pasmodica  / 
cynanche  maligna ;  cynanche  gangrcenosa,  seu  ejpideniica,  sen 
'purpuro-parotidea  \  and  several  other  cynanches,  which  it  is 
needless  to  enumerate.  If  we  prefer  to  call  a  sore  throat 
angina,  then  we  have  angina  apthosa,  angina  oedematosa, 
angina  sicca,  angina  pellicularis,  angina  nasalis,  in  illustra- 
tion of  some  varieties  of  sore  throat  not  already  indicated, 
besides  other  anginas,  which  represent  the  entire  list  of  cynan- 
ches. 

In  view,  therefore,  of  the  great  similarity  of  these  affections 
in  many  respects,  it  will  not  be  illogical  to  take  a  comprehensive 
view  of  sore  throat  in  general ;  selecting  for  observation  in 
detail  such  manifestations  only  as  are  often  very  prominent,  or 


ERYTHEMATOUS  SOEE  THROAT.  79 

which,  from  their  locality  or  their  rapid   progress  toward  a 
fatal  issue,  demand  special  attention. 

COIOION    SOEE   THKOAT ERYTHEMATOUS    SOEE    THEOAT. 

Sore  throat  may  be  acute  or  chronic,  superficial  or  deep- 
seated,  idiopathic  or  symptomatic. 

The  most  frequent  variety  of  acute  sore  throat,  though  the 
symptoms  are  sometimes  exceedingly  moderate,  is  that  of  a 
simple  erythematous  inflammation.  The  mucous  membrane 
of  the  pharynx,  palate,  and  tonsils  is  found  to  be  congested,  or 
of  a  more  or  less  deep  red  color,  often  swollen,  often  with  its 
submucous  connective  tissue  greatly  relaxed,  so  that  it  lies  upon 
the  sub-surface  in  thick  folds  or  rugse.  Sometimes,  though 
more  or  less  of  the  entire  throat  participates  in  the  state  of 
inflammation,  the  swelling  is  confined  to  the  tonsils,  one  or  both 
of  them  ;  their  vessels  being  gorged  with  blood,  and  producing 
by  pressure  a  state  of  hypersesthesia  of  the  gland,  its  entire  sur- 
face is  rendered  exceedingly  tender  and  painful  to  the  touch. 
The  uvula  will  be  likely  to  be  swollen,  with  its  mucous  mem- 
brane relaxed,  so  that  it  may  lie  upon  the  base  of  the  tongue,  and 
thus  induce  an  irritative  tickling  cough.  Sometimes  it  appears 
as  though  glued  to  one  of  the  arches  of  the  palate.  There  is 
usually  more  or  less  heat  and  dryness  of  the  parts,  with  a  moder- 
ate degree  of  difficulty  in  swallowing,  principally  on  account 
of  the  pain  excited  by  the  movement ;  but  sometimes,  ap- 
parently, in  part  from  a  debility  of  the  muscles.  There  is 
almost  always  some  degree  of  fever,  with  more  or  less  accelera- 
tion of  the  pulse.  If  the  disease  is  any  way  active,  the  local 
and  constitutional  symptoms  increase  in  severity,  the  heat  of 
skin  becoming  very  marked,  and  the  pulse  registering  from  100 
to  1'20  and  even  140  beats  in  the  minute.  There  will  be  pain 
in  the  back  and  limbs,  sometimes  of  a  very  severe  character, 
and  increasing  on  motion,  as  though  there  were  some  rheumatic 
element  in  the  complaint ;  and  in  fact  Prof.  Trousseau  and 
others  describe  a  form  of  rheumatic  sore  throat,  not  at  all  allied 
to  that  of  ordinary  inflammation.  Sometimes  the  cervical 
glands  become  swollen  and  painful,  though  not  often. 

The  treatment  of  this  form  of  sore  throat  is  very  simple.     It 


80  SOEE    THROAT. 

is  well  to  confine  the  patient  to  bed  in  order  to  secure  rest; 
and  to  have  a  light  covering  over  him  so  as  to  equalize  the  heat 
of  the  surface  as  well  as  may  be.  If  the  patient  have  recently 
partaken  of  an  ordinary  meal,  an  emetic  will  often  be  of 
service,  inasmuch  as  the  digestion  of  the  food  would  not 
be  apt  to  be  perfect.  For  this  purpose,  mustard  in  water 
is  perhaps  the  best  article,  as  there  is  nothing  to  be  gained  by 
the  use  of  depressant  emetics,  such  as  ipecacuanha  and  anti- 
mony, while  there  is  no  necessity  for  resort  to  those  of  a  more 
stimulant  character,  such  as  the  sulphates  of  copper  and  zinc. 
A  gentle  but  efficient  laxative  is  indicated  to  assist  the  passage 
of  the  matters  in  the  alimentary  canal ;  and  castor  oil,  or  mag- 
nesia, or  rhubarb  may  be  employed  to  this  end.  If  there 
is  costiveness,  a  saline  purge  may  be  administered,  such  as  the 
sulphate  of  magnesia,  or  the  preparation  of  citrate  of  magnesia 
in  general  use.  If  the  pain  is  very  great,  and  the  pulse  fre- 
quent, a  small  amount  of  morphia  and  aconite  may  be 
judiciously  added  to  the  aperient.  For  the  pain  in  the  throat, 
the  free  use  of  demulcent  drinks  may  be  encouraged ;  and 
where  there  is  intense  heat  of  skin,  the  entire  surface  of  the 
body  may  be  sponged  with  slightly  tepid  water,  or  with  water 
containing  a  small  amount  of  vinegar  or  alcohol. 

This,  with  restriction  to  a  very  light  and  easily  digestible  diet 
for  a  day  or  two,  will  usually  be  all  the  treatment  required ;  the 
disease  generally  completing  its  course  in  from  four  or  five  to 
eight  or  ten  days.  If  the  pulse  continues  very  high  the  other 
symptoms  will  not  give  much  evidence  of  subsidence,  and  the 
tincture  of  aconite  root,  in  doses  of  one  or  two  drops,  given  at 
intervals  of  three  or  four  hours,  will  almost  always  have  a  happy 
and  satisfactory  effect ;  but  its  administration  should  be  discon- 
tinued, or  at  least  be  distributed  between  more  lengthened 
intervals,  as  soon  as  it  has  produced  any  marked  effect  upon  the 
pulse  ;  for,  the  activity  of  the  disease  once  abated,  its  own 
tendency  is  to  prompt  recovery.  Care  should  be  taken  to  guard 
against  subsequent  exposure  to  cold,  and  with  this  view  flannel 
underclothing  should  be  worn,  if  such  be  not  already  the  pa- 
tient's custom. 

If  one  side  only  of  the  throat  have  been  prominently  affected, 


ERYTHEMATOUS    SORE    THROAT.  81 

as  is  often  the  case,  there  will  be  a  great  likelihood  that  the 
other  side  will  become  affected  in  turn  after  a  day  or  two  of 
apparent  convalescence ;  and  if  the  patient  has  not  been  careful 
as  to  exposure,  this  second  attack  may  be  more  severe  than  the 
first  one. 

The  local  affection  does  not  often  need  topical  treatment. 
Should  this  seem  necessary,  the  use  of  pieces  of  ice,  or  of  sliglitly 
astringent  lozenges  may  be  employed ;  but  if  the  membrane  be 
very  much  relaxed,  the  use  of  a  weak  solution  of  alum,  prefera- 
bly in  the  form  of  spray,  or  of  a  weak  solution  of  carbolic  acid, 
will  constringe  the  parts,  and  frequently  relieve  their  uneasiness 
in  a  few  hours.  Tannin,  chlorate  of  potassa,  sulphate  of  copper, 
etc.,  have  been  recommended  for  this  purpose,  and  are  often 
beneficial. 

Occasionally  the  uvula  is  a  source  of  a  good  deal  of  discom- 
fort in  this  form  of  sore  throat.  It  is  quite  apt  to  become  (Ede- 
matous from  a  submucous  accumulation  of  serum,  and  may 
attain  the  size  of  the  end  of  the  thumb ;  and  as  the  palate  is 
somewhat  impeded  in  its  action,  and  apt  to  hang  down  in  a 
relaxed  condition,  the  uvula,  already  elongated  by  the  deposit, 
lies  upon  the  base  of  the  tongue  or  immediately  behind  it,  and 
gives  rise  to  a  constant  feeling  of  irritation,  with  a  desire  to 
swallow,  or  a  desire  to  expectorate ;  with  which  effects,  or  with- 
out them,  there  will  be  an  irresistible  disposition  to  relieve  the 
tickling  sensation  by  cough.  Sometimes  the  uvula  interferes 
considerably  with  deglutition,  and  in  some  instances  seems  to 
become  entangled  in  the  alimentary  bolus,  and  half  swallowed 
with  it.  This  swollen  condition  sometimes  comes  on  very 
rapidly,  the  uvula  becoming  distended  and  prolonged  to  twice 
or  thrice  its  normal  size  in  a  few  hours.  It  appears  as  an  (Ede- 
matous swelling,  and  is  easily  recognized  as  the  source  of  con- 
siderable trouble.  A  puncture  or  two  will  usually  suffice  to 
give  vent  to  the  effused  fluids,  after  which  the  swelling  will 
diminish  considerably ;  or  the  mucous  membrane  may  be  trun- 
cated at  its  tip.  It  is  never  necessary  in  these  cases  to  excise 
the  organ,  as  in  cases  of  chronic  elongation.  Sometimes  the 
entire  uvula  is  enlarged  on  account  of  a  sort  of  hemorrhagic 
stasis,  and  occasionally  a  drop  or  more  of  blood  may  exude  to 
6 


82  SOEE   THEOAT. 

the  surface.  Under  these  circumstances  the  condition  is  readily 
relieved  by  scarification  of  the  mucous  membrane,  a  little 
operation  which  can  be  easily  and  rapidly  performed. 

The  tonsils  rarely  give  any  trouble  in  this  variety  of  sore 
throat,  but  if  they  do,  the  treatment  to  be  pursued  in  the  variety 
about  to  be  described  may  be  appropriately  instituted. 

rHLEGMONOUS    SOKE    THEOAT — TONSILLITIS QUINSY. 

Another  variety  of  sore  throat,  evincing  a  higher  grade  of 
inflammatory  action  than  that  just  described,  is  the  phlegmo- 
nous sore  throat,  in  which  the  action  is  not  confined  to  the 
mucous  membrane,  but  seems  to  affect  chiefly  the  submucous 
connective  tissue,  Avhich  is  aptj  to  become  destroyed  in  the  pro- 
cess, leading  to  the  formation  of  abscess,  sometimes  diffuse, 
oftener  circumscribed ;  the  diffuse  abscess  appearing  mostly  in 
broken  down,  depressed,  or  feeble  constitutions. 

In  this  form  of  sore  throat  the  tonsils  are  usually  affected  in 
a  greater  degree  than  the  surrounding  structures,  sometimes  so 
to  a  marked  extent,  and  the  disease  is  designated  as  tonsillitis, 
amygdalitis,  or  quinsy.  The  tendency  of  this  form  of  the 
disease  is  to  terminate  in  suppuration,  yet  it  sometimes  termi- 
nates spontaneously  by  resolution,  and  can  often  be  made  to  do 
so  by  appropriate  treatment.  Another  variety  of  the  disease 
seems  to  spend  its  force  principally  upon  the  submucous  con- 
nective tissue  of  the  pharynx.  This  is  much  less  likely  to 
terminate  in  resolution,  and  it  may  lead  to  very  serious  conse- 
quences, as  it  sometimes  travels  down  the  oesophagus,  where  the 
abscess  is  discharged,  and  occasions  a  permanent  stricture  from 
the  effects  of  the  cicatrization  which  follows ;  a  stricture  likely 
to  lead,  in  many  instances,  to  the  death  of  the  patient.  In  other 
instances,  the  infiltration  into  the  cellular  tissue  of  the  pharynx 
becomes  purulent  with  great  rapidity,  this  action  being 
attended  with  acute  phenomena  of  fever.  The  pus  may  travel 
down  the  entire  oesophagus,  j)roducing  difliculty  of  swallowing, 
which  is  soon  followed  by  difliculty  of  breathing,  from  the 
pressure  exercised  upon  the  larynx  or  trachea,  or  from  blocking 
up  of  the  laryngeal  entrance  by  the  swelling  of  the  pharynx ; 
and  death  results  in  spite  of  treatment,  taking  place  in  from 


PHLEGMONOUS  SOEE  THROAT.  83 

three  to  four  days,  and  sometimes  suddenly.  The  operation  of 
laryngotomy  or  tracheotomy,  in  these  cases,  affords  but  a  tem- 
porary relief.  They  seem  fatal  from  the  very  onset  of  the 
affection. 

The  phlegmonous  variety  of  sore  throat  is  often  ushered  in 
by  a  distinct  chill,  which  is  usually  followed  by  fever  within 
twenty-four  hours.  Besides  the  general  discomfoii;  attendant 
upon  the  febrile  movement,  there  is  very  early  a  sense  of  pain 
and  constriction  in  the  throat,  which  gradually  becomes  more 
and  more  severe,  interfering  with  deglutition.  The  entire 
structures  of  the  throat  usually  present  more  or  less  evidence 
of  inflammation  on  inspection,  but  the  tonsils  in  particular  bear 
the  brunt  of  the  disease ";  sometimes  both  of  them  in  equal  de- 
gree, sometimes  one  much  more  than  the  other,  but  usually  one 
gland  only  being  affected.  The  inflamed  tonsil  will  appear 
swollen,  irregular  in  outline,  and  covered  with  a  thin  layer  of 
non-adherent  whitish  or  creamy-yellowish  tissue,  different  en- 
tirely from  the  patches  observed  in  diphtheria.  The  swelling 
involves  the  arches  of  the  palate  as  well  as  the  sides  of  the 
palate  itself,  which  is  pushed  forward  into  the  mouth  in  the 
form  of  a  tumid,  angry-looking  tumor.  Occasionally  the  tonsil 
enlarges  upward  to  such  an  extent  as  to  press  on  the  orifice  of 
the  Eustachian  tube,  and  cause  deafness.  Sometimes  there  is 
considerable  oedema  of  the  palate  and  uvula,  and  occasionally, 
also,  oedema  of  the  larynx,  to  a  greater  or  less  degree,  likewise. 
The  pain  and  distress  become  intense  as  the  disease  progresses ; 
deglutition  becomes  impossible  in  some  instances,  and  in  others 
it  is  so  painful  that  the  patient  will  not  make  the  attempt  to 
swallow.  The  patient  is  unable  to  close  his  mouth,  or  to  open  it 
widely,  and  he  leans  forward  or  to  one  side  to  allow  the  saliva  to 
dribble  away,  being  unable  to  swallow  it,  or  afraid  to  do  so, 
from  pain,  or  dread  of  suffocation.  The  pain  extends  to  the 
jaws,  which  are  swollen  so  that  the  patient  can  with  difficulty,  or 
perhaps  not  at  all,  open  his  mouth  to  permit  inspection  of  the 
parts.  The  tongue  is  swollen  and  covered  with  a  dingy  secretion. 
The  breath  is  offensive.  There  is  more  or  less  difficulty  of 
,  breathing.  The  voice  is  thick,  or  muffled,  and  there  is  great 
difficulty  in  articulation.     As  the  disease  progresses,  sleep  be- 


84  ;  SORE    THROAT. 

comes  difficult  or  impossible,  sometimes  on  account  of  the 
mechanical  impediment  to  free  respiration,  and  sometimes  on 
account  of  the  disturbance  of  the  nervous  system. 

This  form  of  inflammatory  sore  throat  sometimes  subsides  by 
resolution.  More  frequentl}',  however,  it  proceeds  to  suppura- 
tion An  abscess  forms,  which  opens  spontaneously  if  left  to 
itself.  Its  progress  can  often  be  watched  by  inspection  of  the 
parts,  and  the  spot  at  which  it  is  pointing  be  detected  by  the 
eye  or  by  the  finger.  The  abscess  frequently  bursts  at  night, 
and  sometimes  unconsciously  to  the  patient,  who  swallows  the 
discharge.  At  other  times  he  is  awakened  by  the  pus  in  the 
mouth.  Sometimes  the  abscess  is  burst  in  an  effort  at  vomiting. 
Whenever  or  however  it  opens,  the  relief  is  immediate,  and  the 
inflammation  subsides  quite  promptly.  Cases  of  death  from 
accumulation  of  the  contents  of  the  abscess  in  the  larynx  are 
said  to  have  taken  place  when  the  abscess  has  discharged  at 
night ;  but  they  must  be  rare  and  very  exceptional. 

The  attack,  if  it  runs  through  all  its  stages,  usually  continues 
about  ten  days. 

The  treatment  of  this  disease  must  be  managed  upon  anti- 
phlogistic principles ;  but  it  is  not  advisable  to  have  recourse  to 
general  bleeding,  or  to  leeches,  on  account  of  the  difficulty  of 
administering  food  to  sustain  the  system  and  repair  the  loss  of 
blood.  Early  in  the  attack,  especially  if  the  stomach  be  loaded 
with  undigested  food,  an  emetic  will  render  good  service,  not 
only  to  the  system  at  large,  but  also  to  the  local  affection.  Per- 
haps some  benefit  results  from  the  act  of  vomiting  itself,  due  to 
■the  pressure  of  the  muscles  of  the  velum,  arches,  and  pharynx 
upon  the  tonsil,  driving  onward  some  of  the  blood  with  which 
it  is  engorged.  A  non-depressing  emetic,  such  as  mustard,  is 
the  most  applicable.  We  can  administer  advantageously  a  sa- 
line laxative  mixture,  containing  a  drop  of  tincture  of  aconite 
in  each  dose,  with  the  addition  of  a  little  solution  of  morphia,  if 
the  pain  is  very  great.  The  inhalation  of  steam  from  water 
alone,  or  from  water  impregnated  with  such  substances  as  hops 
or  chamomile  flowers,  or  with  the  watery  extract  of  opium  or 
the  camphorated  tincture,  will  afford  a  great  deal  of  relief  to 
the  throat;  or  the  object  may  be  attained  by  frequent  injec- 


PHLEGMONOUS    SOEE    THROAT.  85 

tions  of  the  spray  of  warm  water  upon  the  parts,  or  of  warria 
water  impregnated  with  cologne,  or  toilet-^nnegar,  applications 
which  are  very  grateful  to  the  patient,  and  which  can  be  re- 
peated ad  libitum. 

Warm  moist  applications,  externally,  give  great  relief,  espe- 
cially if  the  cervical  glands  are  swollen.  For  this  purpose  a 
mass  of  cotton  wool,  wrung  out  of  hot  water,  may  be  placed 
about  the  throat,  and  covered  with  oiled  silk  to  restrain  evapo- 
ration ;  or  the  spongio-piline  may  be  employed  for  the  purpose. 
These  applications  are  much  more  cleanly  than  poultices  of 
flaxseed,  slippery  elm,  etc.,  and  do  not  incommode  by  their 
weight.  If  employed,  they  should  not  be  removed  until  their  suc- 
cessors are  ready  to  replace  them,  and  they  should  be  renewed 
frequently,  so  as  to  maintain  equable  warmth  and  moisture. 
Gargles,  so  often  administered  in  this  complaint,  are  of  very 
little  practical  value,  on  account  of  the  pain  entailed  by  theu- 
use,  which  impairs  their  efficiency  very  much,  and  renders  it 
difficult  to  secure  proper  contact  with  the  affected  parts.  The 
use  of  medicated  sprays,  however,  propelled  upon  the  parts  by 
means  of  appropriate  apparatus,  affords  a  most  admirable  means 
for  employing  local  medication.  A  very  efficient  remedy,  em- 
j)loyed  in  this  way,  is  sulphate  of  copper,  in  a  solution  varying 
from  twenty  grains  to  a  drachm  in  the  ounce  of  water,  and  em- 
ployed freely,  for  several  minutes  at  a  time,  every  two,  three,  or 
four  hours.  Alum,  tannin,  the  preparations  of  zinc,  and  nitrate 
of  silver,  are  also  recom.niended  for  this  purpose.  Appropriate 
substances,  such  as  alum,  tannin,  etc.,  in  the  form  of  powder, 
may  be  blown  upon  the  parts.  The  local  application  of  the 
lunar  caustic  is  recommended  by  some  practitioners,  but  its 
efficient  application  must  be  often  difficult,  and  very  trouble- 
some in  its  effects.  Everything  that  induces  hawking  and 
spitting  should  be  avoided  as  much  as  possible. 

Where  the  tonsils  are  very  much  enlarged  and  the  suffering 
severe,  great  relief  to  the  tension,  pain,  and  distress  will  follow 
scarification  or  puncture  of  the  inflamed  gland.  A  good  me- 
thod is  to  pierce  the  tonsil  in  its  central  portion  with  a  long, 
narrow,  sharp-pointed  bistoury,  and  to  cut  the  instrument  out, 
horizontally,  by  an  incision  through  the  gland  into  the  mouth. 


86  SOEE   THEOAT. 

This  may  be  done  in  two  or  three  places  in  rapid  succession,  and 
is  easily  accomplished  by  a  steady  hand.  The  bleeding  should  be 
encouraged  by  warm  water  taken  into  the  mouth  and  allowed  to 
run  out  again.  The  relief  is  often  immediate,  and  as  the  en- 
gorged vessels  are  emptied  of  their  contents  they  contract,  and 
the  circulation  passes  in  its  accustomed  manner,  producing  a 
tendency  to  resolution.  Many  an  inflamed  gland  has  been  pre- 
vented in  this  way  from  undergoing  the  suppurative  process. 
But  even  when  this  cannot  be  accomplished,  the  alleviation  of 
all  the  more  severe  local  symj)toms  justifies  the  measure.  It  is 
true  that  these  incisions  are  not  universally  recommended,  but  it 
is  equally  true  that  they  are  very  beneficial ;  and  they  are  not  at 
all  painful  to  the  patient,  especially  in  comparison  to  the  suffer- 
ing that  he  is  already  enduring. 

Should  suppuration  have  commenced  already,  there  can 
hardly  be  any  doubt  as  to  the  propriety  of  using  the  knife,  and 
it  should  be  entered  at  the  spot  where  the  abscess  is  most  likely, 
from  appearances,  to  break.  Care  must  be  taken  to  keep  the 
edge  of  the  knife  turned  towards  the  interior  of  the  mouth,  so 
as  to  prevent  injury  from  the  untoward  movements  of  the  pa- 
tient, whose  head  it  may  be  desirable,  under  certain  circum- 
stances, to  have  held  by  an  assistant.  If  the  operator  is  not 
perfectly  sure  of  his  hand  and  of  his  patient,  it  will  be  at  least 
prudent  to  protect  the  blade  of  his  knife  by  covering  it  with 
paper,  linen,  or  plaster  to  within  half  an  inch  or  so  of  the  point, 
or  such  distance  as  he  may  deem  desirable  for  penetration. 

As  soon  as  the  pus  has  been  evacuated,  the  patient  usually 
expresses,  in  grateful  language,  his  sense  of  the  relief  which 
has  been  given  him. 

Two  or  three  days'  intense  suffering  may  be  saved  by  an  early 
puncture  of  the  abscess.  This  once  discharged,  recovery  is 
prompt.  The  general  treatment  is  that  already  recommended 
in  erythematous  sore  throat. 

Durino;  the  course  of  the  affection  care  must  be  taken  to  sus- 
tain  the  patient's  strength,  which  suffers  severely  from  the  vio- 
lence of  the  attack,  the  nervous  comj^lications,  and  the  difficulty, 
and  often  the  impossibility,  of  taking  nourishment.  Liquid 
food  can  almost  always  be  taken,  and  should  be  of  the  most 


PHLEGMONOUS    SORE    THEOAT.  87 

nutritious  character.  If  it  cannot  be  swallowed  in  sufficient  quan- 
tity, we  can  resort  to  nutritive  enemas.  The  parts  should  be 
spared  the  effort  of  swallowing  as  much  as  possible,  and  medi- 
cines that  can  be  given  by  the  rectum  or  by  the  skin  should  not 
be  imnecessarily  administered  by  the  mouth.  An  opium  sup- 
pository to  induce  sleep  is  often  preferable  to  a  dose  of  morphia 
by  the  stomach. 

Although  the  affection  is  usually  limited  to  one  side,  the  other 
side  not  infrequently  becomes  affected  after  the  discharge  of  the 
first  abscess,  exhibiting  in  this  particular  some  similarity  to  the 
action  of  mumps.  If  this  is  about  to  happen,  the  administration 
of  bark,  iron,  and  even  of  stimulants  becomes  necessary  in  order 
to  sustain  the  strength  of  the  patient,  and  enable  him  the  better 
to  endure  the  second  attack. 

Some  persons  are  peculiarly  liable  to  repeated  attacks  of 
quinsy,  recurring  every  year  or  two,  or  even  oftener.  Such 
patients  should  be  very  caatious  about  exposure,  and  be  taught 
to  apply  for  medical  aid  at  the  very  first  symptom  of  the 
malady. 

Frequent  attacks  of  this  kind  result  in  a  permanent  enlarge- 
ment of  the  tonsils,  which  become  indurated  and  often  attain  a 
great  size. 

A  very  desirable  plan  of  securing  additional  protection  from 
attacks  of  sore  throat  of  every  kind,  in  those  particularly  sus- 
ceptible to  them,  is  to  bathe  the  head,  neck,  shoulders,  and 
chest  every  morning,  or  every  night  and  morning,  with  cold 
water. 

The  cold  sponge-bath,  where  it  can  be  tolerated,  is  an  admi- 
rable tonic  to  the  skin,  and,  by  promoting  the  capillary  circula- 
tion, through  it  to  the  system  at  large.  Its  effects  may  be 
heightened,  where  desirable,  by  friction  with  a  towel  after  the 
bath,  and  sometimes  by  friction  before  the  bath  also.  It  is 
rarely  necessary  to  use  a  rough  towel  or  a  flesh-brush  for  this 
purpose,  nnless  there  is  great  difficulty  in  "  bringing  the  blood 
to  the  surface,"  and  the  attainment  of  this  object  is  considered 
sufficiently  important  to  justify  the  harshness.  Where  the  cold 
bath  chills  the  surface,  or  does  not  induce  the  usual  glow  after 
it,  the  specific  gravity  of  the  water  should  be  increased  by  the 


bo  SOEE    THEOAT. 

addition  of  a  due  amount  of  salt.  In  cases  where  this  cannot 
be  borne,  local  baths  of  warm  water,  or  warm  salt  and  water, 
to  small  portions  of  the  surface  at  a  time,  may  be  substituted, 
and  the  system  be  gradually  educated  to  endure  the  cold  water 
as  improvement  progresses. 

The  following  notes  of  a  few  cases  from  the  authors  case- 
books will  illustrate  the  method  of  treatment. 

Tonsillitis. — E..  D.,  laborer,  set.  30.  Acute  tonsillitis,  several 
days'  duration.  A  solution  of  sulphate  of  copper  was  applied 
locally  twice  a  day  for  four  days,  and  on  the  fifth  he  was  well. 

Ulcerative  Tonsillitis.  —  I^eil  F.,  set.  23,  applied  April 
24,  1867,  after  two  days'  intense  suffering  with  sore  throat, 
dysphagia,  and  dyspnoea,  the  severity  of  which  were  still  in- 
creasing. The  tonsils  M^ere  swollen  and  ulcerated,  and  occluded 
the  isthmus  between  mouth  and  pharynx.  A  nebulized  solution 
of  sulphate  of  copper,  40  grs.  to  the  oz.,  was  applied  locally ;  a 
prescription  written  for  10  grs.  each  of  calomel  and  jalap,  to 
be  taken  at  night,  with  directions  to  take  a  dose  of  Epsom 
salts  in  the  morning.  The  local  applications  were  repeated 
twice  a  day  for  two  days,  then  daily  for  two  days,  which  com- 
pleted the  necessary  attendance. 

About  the  same  time,  Catherine  K ,  set.  35,  unmarried, 

applied  with  an  ulcerative  tonsillitis,  affecting  the  right  side 
especially.  A  pill  of  Croton  oil  and  calomel  was  ordered  to 
overcome  a  constipation  of  ten  days'  duration,  which  operated 
twice  the  next  day  with  a  satisfactory  eifect.  Nitrate  of  silver 
was  applied  locally  to  the  parts,  but  did  not  appear  to  be  as 
beneficial  as  the  sulphate  of  copper,  which  was  substituted  for 
it  on  the  third  day,  with  better  effect. 

John  B had  had  sore  throat  for  several  days  (April  3, 

1867).  When  sent  to  me  the  tonsils  were  seen  to  be  very  much 
enlarged  and  pressing  against  each  other,  so  that  the  uvula  lay 
over  them  as  upon  a  shelf.  The  tonsils  were  ulcerated,  and 
there  was  a  purulent  discharge.  There  was  very  great  dyspha- 
gia, and  considerable  difliculty  in  breathing. 

The  tonsils  were  scarified,  and  a  solution  of  sulphate  of  cop- 
per, 30  grs.  to  the  oz.,  freely  applied  by  means  of  the  spray- 
producer.     Respiration  and  deglutition  were  at  once  improved. 


ULCERATED    SOEE   THROAT.  89 

Tlie  local  applications  were  kept  up  twice  a  day  for  four  days, 
by  which  time  all  signs  of  active  disease  had  abated.  One 
week  after  this  the  right  tonsil  was  in  part  excised,  on  account 
of  a  permanent  hypertrophy. 

ULCEEATED    SORE   THROAT. 

The  peculiar  characteristic  of  this  form  of  sore  throat  is  in- 
dicated by  its  name.  Though  but  moderately  severe  in  some 
instances,  in  others  it  exhibits  from  its  very  commencement  a 
tendency  to  phagedenic  ulceration  of  a  malignant  character ; 
producing  gangrenous  sloughs,  which  destroy  large  portions  of 
tissue  and  extend  into  the  vessels,  giving  rise  to  hemorrhage 
which  is  sometimes  fatal.  It  is  that  form  of  sore  throat  often 
described  under  the  name  of  angina  maligna  or  tonsillitis 
inaligna,  indicating  the  serious  nature  of  the  malady.  It  is 
not  a  frequent  affection,  and  is  usually  attended  with  that  gen- 
eral condition  of  system  denominated  typhoid.  It  sometimes 
follows  scarlatina,  and  is  occasionally  attendant  upon  diphtheria. 
Sometimes  it  supervenes  upon  measles,  small-pox,  dysentery, 
and  typhoid  fever.  It  is  also  met  with  in  syphilitic  sore  throat, 
and  sometimes  attends  epithelial  cancer  of  the  throat;  begin- 
ning usually  in  these  instances  in  the  palate,  and  extending  to 
the  pharynx  and  tonsils.  It  is  rarely  a  sequel  of  inflammatory 
sore  throat. 

There  is  often,  at  the  same  time,  an  irregular  eruption  on  the 
cutaneous  surface,  principally  of  an  erythematous  character. 
Fever  is  present,  always  of  a  low  type,  with  a  dark  flush  upon 
the  face,  a  glassy  look  about  the  eyes,  a  haggard  expression  of 
countenance  ;  and  as  the  disease  progresses,  there  is  a  fetid 
odor  of  the  breath.  The  pain  is  not  so  severe  as  in  the  forms 
of  sore  throat  already  described,  except,  perhaps,  in  children,  in 
whom  it  is  difiicult  to  estimate  the  exact  amount  of  suffering. 
There  is  some  dysphagia,  but  rarely  actual  difliculty  of  swallow- 
ing to  any  marked  degree.  On  inspection  of  the  parts,  the 
tongue  will  be  found  coated  with  a  dark  creamy  secretion ;  the 
tonsils  will  be  swollen  and  of  a  deep-red  color;  and  there  will 
be  swelling,  if  not  oedema,  of  the  palate  and  uvula.  The  pha- 
rynx, too,  participates  in  the  condition  of  the  surrounding  parts, 


90  SORE    THEOAT. 

and  sometimes  to  a  marked  extent.  Soon  after  the  commence- 
ment of  the  affection,  dark  ash-colored  ulcers  will  be  seen  occu- 
pying the  surface  of  the  tonsil  and  the  surrounding  structures. 
These  will  be  excavated.  The  ulcers  soon  slough,  and  there 
oozes  from  them  a  fetid,  ichorous,  or  sanious  discharge.  The 
cervical  glands  become  swollen  and  painful.  Although  the 
voice  becomes  weak  and  muffled,  there  is  rarely  any  active  par- 
ticipation in  the  disease  involving  the  larynx.  Extension  to 
the  upper  parts  of  the  pharynx  and  to  the  nasal  passages  is 
quite  frequent. 

The  ulceration  extends  rapidly  and  exhibits  the  phagedenic 
character,  and  when  the  sloughs  separate  from  the  tissues  they 
expose  deep  ulcerations  with  excavated  edges  of  a  dark  or 
yellowish  appearance.  This  gangrenous  condition  may  be 
confined  to  the  tonsil,  but  more  frequently  extends  to  the 
adjacent  parts,  destroying  in  its  progress  the  uvula,  and  often 
more  or  less  of  the  soft  palate.  Sometimes  it  is  impossible  to 
arrest  the  progress  of  the  gangrene,  and  it  extends  from  the 
pharynx  to  the  subjacent  structures,  penetrating  the  carotid 
artery  and  producing  fatal  hemorrhage.  A  recent  instance  of 
this  nature  occurring  in  a  case  of  phthisis  is  recorded  by  Mr. 
Robert  Grahame.'  The  phagedenic  action  commenced  in 
the  pharynx ;  and  in  spite  of  active  treatment,  invaded  both 
tonsils,  the  uvula,  the  soft  palate,  and  the  lateral  walls  of  the 
pharynx;  producing  hemorrhage  which  required  ligation  of 
the  common  carotid  artery.  The  operation  was  successful  in 
its  result. 

The  matters  discharged  escape  by  the  mouth  and  nose,  and 
are  extremely  fetid  in  odor,  so  fetid  that  their  effluvium  has 
been  sometimes  compared  to  that  from  the  f geces.  Often  diar- 
rhoea sets  in  towards  the  last,  soon  followed  by  death. 

The  diagnosis  of  this  disease  presents  no  difficulty  when  the 
case  has  made  any  progress ;  and  in  the  earlier  stages  it  may 
be  recognized  by  the  depressed  state  of  the  general  system,  the 
absence  of  intense  pain,  and  the  dark  unhealthy  appearance  of 
the  affected  parts. 

'  London  Lancet^  Aug.  27th,  1870,  p.  290. 


ULCERATED    SOEE    THROAT.  91 

The  prognosis  is  unfavorable,  though  cases  often  recover. 
Death  may  occur  by  syncope,  coma,  or  from  gradual  exhaus- 
tion of  the  vital  forces. 

"When  cases  of  this  kind  recover,  there  often  remains  a  hor- 
rible degree  of  deformity  to  mark  the  ravages  of  the  disease. 
As  cicatrization  occurs,  the  position  of  the  parts  becomes  very 
much  changed.  The  palate  adheres  by  its  sides,  and  sometimes 
almost  by  its  entire  surface,  to  the  wall  of  the  pharynx,  and  in 
some  instances  there  has  been  complete  occlusion  of  the  upper 
or  nasal  portion  of  the  pharynx.  The  worst  case  seen  by  the 
writer  was  one  in  which  the  space  between  the  adherent  soft 
palate  and  the  posterior  wall  of  the  pharynx  was  barely  large 
enough  to  admit  the  end  of  the  finger.  There  is  more  or  less 
alteration  of  voice,  some  difficulty  in  articulation,  and  often 
serious  impediment  to  comfortable  deglutition,  and  to  satisfac- 
tory use  of  the  pocket-handkerchief. 

Operations  for  the  relief  of  this  condition  have  been  pro- 
posed, but  there  is  considerable  difficulty  in  the  after-treat- 
ment, in  consequence  of  the  tendency  of  the  parts  to  reunite. 
Cauterization  of  the  cut  edges,  and  the  frequent  interposition 
of  bits  of  sponge  or  linen  between  the  divided  surfaces,  would 
be  required  to  prevent  this  re-adhesion.  It  may  be  that  severing 
the  parts  with  the  galvano-cautery  instead  of  the  knife  would 
promise  a  more  speedy  hope  of  success. 

The  treatment  of  this  form  of  sore  throat  must  be  of  the 
most  active  and  supporting  character;  that,  in  a  word,  which 
\yould  be  adopted  for  the  arrest  of  gangrene  anywhere. 

Food  of  the  most  nourishing  quality,  such  as  concentrated 
broths,  milk,  cream,  and  eggs,  is  to  be  administered  as  fi^eely  as 
the  patient  can  be  made  to  take  it ;  and  wine  or  brandy  may  be 
added  to  the  food  or  given  separately,  and  with  no  stingy  hand. 
The  forces  of  the  system  are  to  be  kept  up  at  all  hazards. 
Medicinally,  the  sulphate  of  quinine  in  large  doses,  or  the 
liberal  use  of  the  old  decoction  of  cinchona,  are  indicated ;  to 
which  may  be  added,  if  desired,  the  tincture  of  the  chloride  of 
iron.  For  my  own  part,  I  would  rely  chiefly  on  eggnog,  home- 
made beef  essence,  and  quinine.  Fortunately,  swallowing  is 
not  usually  very  difficult,  and  sufficient  nourishment  may  be 


92  SORE   THROAT. 

taken  by  the  mouth.  Should  the  dysphagia  be  very  great,  arti- 
ficial measures  must  be  resorted  to  for  the  iutroduetion  of  nutri- 
ment. Enemas,  containing  a  few  ounces  of  beef  essence,  an 
ounce  of  port  wine,  and  ten  or  fifteen  grains  of  quinine  can  be 
administered  three  or  four  times  a  day. 

The  local  treatment  is  also  important.  If  the  disease  is 
superficial,  the  ulceration  not  having  extended  beneath  the 
mucous  membrane,  the  best  applications  will  be  those  of 
hydrochloric  acid,  nitric  acid,  caustic  potassa,  bromine,  etc. ;  sub- 
stances that  will  destroy  the  diseased  tissues  promptly,  so  as  to 
expose  a  healthy  surface  beneath  them.  If  this  cannot  be  done 
for  fear  that  the  process  is  involving  the  blood-vessels,  or  if  it 
prove  unsuccessful  in  restraining  the  further  progress  of  the 
ulceration,  we  are  compelled  to  depend  on  our  constitutional 
measures,  and  to  resort  simply  to  palliative  remedies  locally, 
such  as  weak  solutions  of 'nitrate  of  silver,  dihite  hydrochloric 
acid,  alum,  etc.,  to  which  the  extract  of  opium,  or  some  other 
preparation  of  it,  may  be  advantageously  added.  Washes  or 
sprays  of  chlorate  of  potassa,  bromide  of  potassium,  and  the 
various  remedies  emploj^ed  for  the  relief  of  ordinary  sore  throat, 
are  often  very  comforting,  though  without  active  influence  on 
the  disease.  If  the  disease  is  progressing  in  the  region  of  the 
great  vessels,  measures  for  compression  should  be  at  hand  for 
the  use  of  the  attendant,  and  the  surgeon  should  be  prepared 
for  the  emergency  of  securing  the  carotid  artery. 

_  MEMBRANOUS    SOKE   THKOAT. 

There  is  a  variety  of  sore  throat,  almost  always  more  or  less 
met  with  at  all  seasons,  characterized  by  the  exudation  of 
a  fibrinous  material  which  coagulates  into  a  pellicle  or  false 
membrane.  These  cases  are  very  often  mistaken  for  diphtheria, 
and  account  for  much  of  the  success  claimed  for  the  various 
treatments  of  that  disease.  For,  apart  from  the  immediate 
danger  sometimes  attending  the  mechanical  obstruction  in 
cases  implicating  the  larynx, — cases,  however,  which  ai'e  very 
rare, — the  tendency  of  this  affection  is  to  recovery;  while  a  sim- 
ilar tendency  in  diphtheria  is,  as  we  shall  see,  doubtful.  This 
form  of  sore  throat  is  often  met  with  during  the  prevalence  of 


MEMBEAIS^OUS    SOEE    THROAT.  98 

> 

diplitheria,   and   sometimes  may  be   a  starting-point   of  that 

disease.  Discrimination  is  therefore  of  paramount  importance. 
The  peculiar  manifestation  of  the  disease  is  preceded  for 
two  or  three  days  by  the  symptoms  of  ordinary  sore  throat, 
supervening  upon  a  chill  with  febrile  reaction,  and  symptoms 
of  general  derangement  of  the  digestive,  secretive,  and  nervous 
system.  The  most  frequent  cause  is  exposure  to  cold  when  the 
body  is  heated,  or  in  a  state  of  perspiration.  The  throat 
affection  is  usually  confined  to  one  side,  and  involves  the 
cervical  or  submaxillary  glands  to  a  moderate  degree  only. 
There  is  pain  and  difhculty  of  deglutition,  an  uneasy  or  painful 
sense  of  heat  and  dryness  in  the  throat,  extending  upwards 
towards  the  ear,  sometimes  into  the  nasal  passages,  and  occa- 
sionally into  the  larynx. 

On  examining  the  throat  there  will  be  found  tumefaction 
of  the  tonsils,  which  will  be  seen  to  be  covered  with  a  wdiitish 
or  yellowish- white  pultaceous  exudation,  but  slightly  adlierent 
to  the  mucous  membrane. 

It  was  remarked  by  Brettonneau,  insisted  on  by  Trousseau, 
and  demonstrated  by  Dr.  Gubler,  that  this  affection  is  essentially 
an  herpetic  eruption  of  the  mucous  membrane  of  the  throat. 
From  their  investigations  it  appears  that  within  a  few  hours 
after  the  commencement  of  the  affection  there  may  be  observed 
on  the  tonsils,  palate,  or  pharynx,  a  red  eruption,  more  or  less 
confluent,  but  sometimes  discrete,  which  soon  becomes  ulcera- 
ted ;  the  ulcerations  becoming  covered  almost  immediately  with 
a  plastic  exudation  of  a  grayish-white  color. 

The  exudation,  spreading  beyond  the  limits  of  the  ulceration, 
becomes  coalesced  with  similar  exudations  covering  neighboring 
ulcerations  which  have  commenced  in  the  same  manner, 
forming,  in  this  way,  membranous  patches  of  considerable 
extent.  The  initial  point  of  local  disturbance  has  been  an 
herpetic  vesicle,  wdiich,  shortly  after  its  production,  has  become 
ruptured,  leading  to  the  result  just  described.  Prof.  Trousseau 
did  not  consider  the  mere  amount  of  eruption  sufhcient  to 
account  for  the  entire  extent  of  membranous  deposit.  He 
believed  that  the  local  inflammation  preceding  the  develop- 
ment of  the  herpetic  vesicle,  and  accompanying  and  following 


94  SOEE    THEOAT. 

it,  extends  to  the  adjacent  parts,  and  there  manifests  itself  by 
redness,  swelling,  and  oedematous  infiltration  ;  and  that  this  in- 
flammation, althongh  not  ulcerative,  favors  an  exudation  of 
fibrinous  material,  the  same  as  that  which  appears  upon  the 
ulcerated  surfaces.  That  there  is  ulceration  of  the  mucous 
membrane  iilflamed  in  this  manner  is  perhaps  likely,  f roiu  the 
fact  which  Prof.  Trousseau  himself  mentions  in  this  very 
connection;  and  that  is,  that  when  this  deposit  is  detached,  as  by 
a  pledget  of  charpie,  there  is  found  below  it  an  ulceration 
more  or  less  extensive;  although  there  may  be  but  a  small 
point  of  ulceration  remaining,  or  even  no  trace  of  primitive 
lesion  at  all,  from  complete  cicatrization  of  the  mucous  mem- 
brane. 

In  many  of  these  cases  an  herpetic  eruption  exists  at  the  same 
time  at  the  angles  of  the  mouth,  on  the  internal  surface  of  the 
lips  and  cheeks,  or  upon  the  tongue ;  and  under  such  circum- 
stances there  can  be  no  doubt  about  the  diagnosis. 

The  prognosis  is  favorable  in  this  disease,  recovery  being 
spontaneous  in  eight  or  ten  days,  in  the  majority  of  cases ; 
still  it  has  been  known  to  prove  fatal,  especially  in  children,  by 
extension  into  the  larynx,  and  even  further  into  the  air-passages ; 
death  taking  place  by  asphyxia. 

Prof.  Dickson  mentions,  in  his  lectures,  a  fatal  case  of  this 
kind  in  a  child,  in  whom,  after  death,  he  found  the  deposit  lin- 
ing the  larger  and  smaller  bronchi  of  the  w^hole  of  the  left 
lung.  The  deposit  was  in  a  tubular  form,  and  so  extensive  that 
he  dissected  off  portions  of  it  "as  long  as  his  finger.  He  con- 
siders it  analogous  to  a  form  of  tubular  diarrhoea  ^  described  by 
Good,  in  which  the  pseudoplasm  forms  a  tube  in  the  intestines ; 
and  refers  to  a  case  mentioned  by  West,  i]i  which  a  membrane 
of  this  kind  lined  the  whole  oesophagus. 

This  membranous  deposit  is  often  found  upon  the  ulcerated 
surfaces  of  mucous  membrane,  and  also  upon  cutaneous  ulcers, 
and  the  broken  cuticle  of  blistered  skin.  It  presents  a  similarity 
to  the  deposit  found  upon  similar  surfaces  in  diphtheria,  but 

^  This  form  of  disease  has  been  recently  described  by  Dr.  Da  Costa  as  mem- 
branous enteritis.     Am.  Jour.  Med.  Sci.,  Oct.,  1871,  p.  321. 


membea:n"OUS  soee  theoat.  95 

does  not  constitute  diphtlieria,  there  being  an  entire  absence  of 
the  toxic  symptoms  of  that  disease. 

The  treatment  of  the  form  of  membranous  sore  tliroat  under 
consideration  is  very  simple.  Laxatives,  demulcents,  and  ano- 
dynes are  called  for,  to  moderate  the  general  disturbance  of 
system.  The  local  affection  does  not  demand  active  interference, 
and  may  be  let  alone  if  the  suffering  is  not  severe.  Solutions 
of  alum  or  borax  may  be  projected  upon  the  parts  in  the  form 
of  spray ;  or  they  may  be  applied  by  means  of  the  camel-hair 
pencil.  These  topical  methods  are  preferable  to  the  use  of 
gargles,  just  as  in  other  affections  of  the  throat,  in  virtue  of 
the  avoidance  of  muscular  effort  in  the  act  of  gargling. 

Although  this  disease  is  usually  of  a  transient  character,  last- 
ing on  the  average  from  eight  to  ten  days,  cases  now  and  then 
occur  in  which  trains  of  the  manifestations  described  suc- 
ceed one  after  the  other ;  the  disease  of  the  throat  continuing 
for  weeks  and  even  months.  Under  these  circumstances,  ap- 
plications of  dilute  muriatic  acid  are  said  to  have  a  more  posi- 
tive and  permanent  effect  upon  the  exudation  than  the  milder 
ones  of  borax  and  alum,  or  even  the  application  of  nitrate  of 
silver.  Warm  fomentations  about  the  throat,  the  inhalation  of 
the  vapor  of  warm  water,  simple  or  medicated  with  opium, 
with  rest  in  the  recumbent  position,  the  use  of  cinchona  and 
iron  as  tonics,  and  the  maintenance  of  a  nutritious  diet,  would 
seem  to  form  the  most  appropriate  method  of  management  for 
these  cases.  < 

This  form  of  membranous  sore  throat  sometimes  becomes  the 
starting-point  of  malignant  or  phagedenic  sore  throat.  It  has 
already  been  stated  that  when  diphtheria  is  prevalent,  common 
membranous  sore  throat  may  invite  an  attack  of  diphtheria ; 
and  that  it  is  often  met  with  during  the  prevalence  of  diphtheria. 
If,  therefore,  there  be  any  doubt  as  to  its  nature — and  doubt  may 
readily  arise  under  such  circumstances — the  safest  plan  for  the 
practitioner  would  be  to  treat  it  as  if  it  were  diphtheria.  There 
is  nothing  to  be  lost  if  the  case  should  turn  out  to  have  been 
only  common  membranous  sore  throat ;  and  everything  will 
have  been  gained  should  it  turn  out  to  be  diphtheria.  Fnder 
the  former  circumstances,  the  practitioner  must  be  on  his  guard 


96  SOEE    THROAT. 

against  vaunting  any  new  remedy  as  having  cured  a  case  of 
diphtheria.  As  already  mentioned,  a  great  deal  of  confusion 
has  arisen  regarding  the  therapeutics  of  diphtheria  for  want  of 
due  discrimination  in  this  very  respect. 

The  following  case  of  membranous  sore  throat  presented  some 
unusual  features  which  I  have  met  with  but  once  or  twice : — 

Patrick  F.  (Jan.  14,  1867)  had  had  sore  throat  with  inability 
to  swallow  for  several  days.  The  palate,  arches,  and  pharynx 
were  covered  with  a  lead-colored  fibrinous  exudation.  I  applied 
locally  a  solution  of  acid  nitrate  of  mercury,  one  part  to  ten 
of  water,  which  excited  profuse  expectoration  of  large  quantities 
of  dark,  ropy,  fetid  mucus,  hanging  in  strings  from  his  mouth  to 
the  floor,  and  continuing  to  be  discharged  for  fully  half  an 
hour.  A  cathartic,  containing  ten  grains  of  blue  mass,  five  of 
jalap,  and  one  of  ipecacuanha,  was  given  at  bed-time,  and  a  dose 
of  Epsom  salts  in  the  morning ;  and  after  this,  he  was  instructed 
to  take  a  solution  of  muriate  of  ammonia  in  glycerine,  ten 
grains  to  the  ounce,  j?rc»  re  nata,  as  an  expectorant.  The  next 
day  there  was  no  longer  any  difficulty  in  swallowing,  and  he  was 
able  to  partake  of  a  hearty  meal  of  meat.  He  had  no  further 
trouble.  This  patient  had  been  placed  under  my  care  as  a  case 
of  diphtheria. 


DIPHTHEEIA.  97 


CHAPTEE    IV. 


DIPHTHEEIA. 


-  Diphtheria  is  an  infectious  disease  of  a  low  type,  whose 
principal  local  manifestation  is  the  formation  of  a  pseudo-mem- 
branous deposit  in  the  pharyngeal  and  naso-pharyngeal  region. 
It  seldom  attacks  persons  in  first-rate  health,  living  under  good 
hygienic  influences,  but  rather  those  broken  down  by  over- work, 
disease,  abstinence,  or  indulgence  ;  and  especially  patients  sub- 
ject to  sore  throat,  acute  or  chronic,  particularly  when  the 
mucous  membrane  of  the  throat  is  in  part  denuded  of  its  epi- 
thelium. It  attacks  persons  of  all  ages,  but  children  and  youth- 
ful adolescents  most  frequently. 

Although  sometimes  appearing  sporadically,  diphtheria  is 
essentially  an  endemic  disease.  It  seems  to  be  due,  at  least  in 
part,  to  the  presence  of  some  cryptogamic  vegetable  poison  in 
the  atmosphere,  which  alights  upon  the  pharynx  during  the  act 
of  inspiration.  There  the  low  organism  continues  to  be  prop- 
agated, and  is  absorbed  into  the  blood,  which  it  poisons.  One  of 
the  effects  of  this  poison  is  a  low  grade  of  inflammation,  giving 
rise  to  the  exudation  of  plastic  material  similar,  as  far  as  has 
been  ascertained  by  chemical  and  microscopical  examination,  to 
the  false  membrane  formed  in  croup ;  similar  too,  it  is  said,  to 
the  plastic  exudation  that  follows  the  local  application  of  can- 
tharides,  ammonia,  hydrochloric  acid,  and  other  vesicants. 
Evidence  of  the  cryptogamic  vegetation  is  occasionally  found  in 
the  microscopical  examination  of  the  diphtheritic  deposit  itself, 
and  it  is  difficult  to  believe  that  it  can  be  altogether  due  to  de- 
velopments which  have  taken  place  within  the  bodj^.  That  the 
disease  is  infectious  is  sufficiently  proven  by  the  sad  fact  that 
some  of  the  members  of  our  own  profession  have  paid  the  death 
penalty  of  contracting  this  disease,  from  direct  contact  of  the 
material  coughed  into  their  faces  while  cauterizing  the  throats 
7 


98  DIPHTHEEIA. 

of  their  ]3atients,  or  voluntarily  drawn  into  their  mouths  while 
rescuing  a  tracheotomized  patient  from  asphyxia,  by  sucking  out 
through  the  wound  the  accumulations  threatening  the  suffocation. 

The  fact  that  various  experimenters  have  failed  to  infect 
themselves  with  diphtheria  by  placing  the  23lastic  material  in 
contact  with  their  own  mucous  membranes,  or  even  beneath 
them  by  the  aid  of  the  lancet,  only  proves  that  it  is  not  inocu- 
lable,  not  that  it  is  not  contagious. 

Diphtheria  usually  begins  with  sore  throat;  with  redness  and 
tumefaction  of  the  tonsils,  palate,  and  pharynx,  usually  on  one 
side  or  the  other,  sometimes  upon  both.  If  one  side  is  unaf- 
fected at  the  commencement,  it  is  apt  to  become  involved 
during  the  course  of  the  disease.  The  submaxillary  and  cervi- 
cal glands  of  the  side  affected  are  also  swollen  and  tender. 
These  symptoms  are  not  always  of  sufficient  extent  to  excite 
alarm.  Cases  are  not  infrequent  in  which  patients  have  con- 
tinued about  their  usual  employments  while  the  disease  was 
progressing,  its  nature  having  become  discovered  often  too  late 
to  prevent  a  fatal  termination.  )  After  a  few  hours,  a  day  or 
two,  or  even  longer,  there  will  be  noticed,  somewhere  upon  the 
tonsils,  soft  palate,  or  pharynx,  a  whitish  or  grayish  exudation, 
usually  in  patches.  This  may  remain  confined  to  a  limited 
space,  or  it  may  extend  over  the  entire  pharynx,  sometimes 
into  the  larynx  and  thence  down  the  trachea,  sometimes  mount- 
ing the  pharynx  and  entering  the  nares.  Its  appearance  in 
this  latter  situation  is  denotive  of  the  gravest  danger,  even 
though  there  should  be  but  little  evidence  of  the  disease  else- 
where, or  little  evidence  of  general  disturbance.  The  extension 
of  the  disease  to  the  nares  may  be  dreaded  when  there  are 
symptoms  of  coryza  and  epistaxis.  The  false  membrane,  at  first 
thin,  particularly  at  its  edges,  soon  thickens,  and  often  becomes 
darker  in  color,  presenting  the  yellowish  tinge  and  granular 
appearance  of  chamois  leather.  By  imbibition  of  the  coloring- 
matters  of  the  blood  it  often  becomes  brownish,  or  even  almost 
black.  The  constitutional  symptoms  are  usually  those  of  a 
typhoid  character,  there  being,  as  a  rule,  comparatively  little 
febrile  excitement,  but  rather  a  degree  of  general  languor  and 
nervous  debility.  \ 


DIPHTHEEIA.  99 

Althougli  the  pharynx  or  its  immediate  neighborhood  is  the 
usual  seat  of  the  deposit,  it  is  also  liable  to  occur  upon  the 
other  mucous  outlets,  and  upon  the  denuded  skin;  the  latter 
circumstance,  perhaps,  an  additional  argument  in  favor  of  the 
local  nature  of  the  affection  at  tlie  initial  period  of  disturbance. 
In  a  case  which  progresses  favorably  without  local  treatment, 
the  false  membrane,  after  a  few  days,  gradually  disappears 
from  circumference  to  centre.  This  exfoliation  may  be  fol- 
lowed b}^  a  reappearance  of  the  deposit  a  second,  and  even  a 
third  or  a  fourth  time.  Similar  reproduction  will  follow  its 
removal  by  artificial  means.  AYhen  thus  removed,  the  parts 
beneath  do  not  exhibit  any  evidence  of  ulceration,  even  though 
the  deposit  had  resembled  that  covering  a  gangrenous  ulcer. 
There  is  usually  a  slight  excoriation  noticed,  due  to  the  removal 
of  the  epithelium,  the  presence  of  which  can  be  discovered  upon 
the  false  membrane  by  means  of  the  microscope. 

Deglutition,  as  a  rule,  is  not  difficult,  unless  there  be  a  great 
deal  of  swelling,  but  it  is  nevertheless  often  impeded  on  ac- 
count of  paralysis  of  the  pharyngeal  and  palatine  muscles,  even 
when  the  swelling  is  but  moderate.  There  will  be  no  difficulty 
of  respiration  until  the  membrane  has  become  formed  within 
the  larynx,  an  occurrence  which  does  not  take  place  until  after 
it  has  made  its  appearance  upon  the  pharynx.  Its  gradual  ex- 
tension can  be  watched  in  the  larpigoscopic  mirror,  mounting 
the  lingual  face  of  the  epiglottis,  then  covering  its  larjmgeal  face 
until  it  appears  as  if  ensheathed  within  the  finger  of  a  leather 
'  glove,  and  then  mounting  the  aryteno-epiglottic  folds  in  its 
course  over  the  interior  of  the  larynx. 

Diphtheria  is  pre-eminently  a  fatal  disease,  not  alone  from 
the  presence  of  the  membrane  in  the  larynx,  as  in  croup,  but 
principally  from  the  blood-poisoning  which  has  taken  place, 
altering  the  blood  in  character  as  well  as  color,  and  rendering 
it  unfit  for  the  purposes  of  nutrition. 

There  are  evidences  of  this  systemic  poisoning  other  than 
those  which  mark  the  local  manifestations  of  the  disease.  These 
are  the  asthenic  or  typhoid  condition  of  s^'stem,  the  existence 
of  albuminuria  during  the  course  of  the  disease,  and  a  disposi- 
tion to  paralysis  of  the  muscles  concerned  in  deglutition ;  once 


100  DIPHTHEEIA. 

in  a  while  of  the  muscles  of  phonation,  not  infrequently  of  the 
muscles  of  visual  accommodation,  and  sometimes  of  the  muscles 
of  the  limbs  and  other  portions  of  the  body,  occasionally  amount- 
ing to  general  paralysis.  This  diphtheritic  paralysis  follows 
a  state  of  convalescence  from  the  immediate  affection.  This 
shows  that  the  poison  has  affected  the  nervous  system,  and  to  an 
extent,  perhaps,  commensurate  with  the  gravity  of  the  pre- 
vious symptoms. 

Fortunately,  the  paralysis  following  diphtheria  is  not  of  a 
permanent  character,  and  usually  yields  readily  to  treatment  by 
local  electrization. 

Diphtheria  must  be  discriminated  from  common  membranous 
sore  throat  on  the  one  hand,  and  from  croup  on  the  other. 
It  is  believed  that  the  descriptions  of  these  diseases  given  under 
their  respective  heads  will  be  f omid  to  afford  the  points  neces- 
sary for  differentiation. 

The  treatment  of  diphtheria  should  be  active  and  efficient. 
Under  the  view  that  it  is  of  parasitic  origin,  and  that  it  is  essen- 
tially a  poisoning  of  the  blood,  producing  an  impairment  of  the 
general  system,  the  treatment  would  be  directed  towards  de- 
stroying the  cause  as  much  as  possible,  and  supporting  the 
strength  of  the  patient  by  means  of  food  of  the  most  nourishing 
character,  aided  by  the  administration  of  tonics  and  stimulants. 
Low  forms  of  organism  are  destroyed  by  contact  with  sulphurous 
acid,  and  this  explains  much  of  the  success  of  the  sulphur  treat- 
ment which  has  been  so  highly  recommended  from  various  reli- 
able sources.  This  treatment  may,  in  the  iirst  instance,  be  directed 
upon  the  local  manifestations  of  the  disease,  and  may  also  be 
directed  towards  introducing  sulphur  into  the  blood.  Local  treat- 
ment has  been  highly  extolled  in  diphtheria  ;  it  has  been  unhesi- 
tatingly denounced ;  and  both  denunciation  and  praise  have  pro- 
ceeded from  good  authority.  Those  who  have  but  a  superficial 
knowledge  of  diseases  of  the  throat  are  apt  to  consider  local 
treatment  as  signifying  the  use  of  the  nitrate  of  silver.  Now  if 
we  examine  into  the  cases  which  have  given  rise  to  this  differ- 
ence of  opinion,  we  shall  find  very  often  that  the  local  treat- 
ment which  has  been  effectual  has  consisted  in  the  employment 
of  materials  containing  sulphur  or  some  other  agent  capable  of 


DIPHTHEEIA.  101 

destroying  low  organisms.  Nitrate  of  silver,  tliere  is  no  donbt, 
has  been  jiroductiA^e  of  good  results  in  some  instances,  but  it  is 
the  very  remedy  which  is  denounced  the  most,  and  there  is  no 
doubt  that  it  is  sometimes  actually  injurious.  But  we  find 
Trousseau  and  others,  who  recommend  the  use  of  nitrate  of 
silver  very  highly,  telling  us  that  they  have  found  results  in 
many  respects  equal,  and  sometimes  superior  to  those  of  nitrate 
of  silver,  in  sulphate  of  copper  and  in  alum.  It  may  be  stretch- 
ing a  point  very  wide  to  attribute  the  beneficial  effects  to  the 
presence  of  sulphur  in  these  salts  ;  but  when  we  reflect  on  the 
fact  that  the  local  application  of  the  sulphur  itself  and  of  sul- 
phurous acid  is  still  more  efficacious,  we  cannot  help  thinking 
that  there  may  be  some  foundation  for  the  notion.  Carbolic 
acid  applications  have  likewise  been  shown  to  be  efiicacious, 
and  perhaps  on  the  same  principle,  as  being  antagonistic  to 
atmospheric  germs. 

To  the  eflicacy  of  the  sulphur  treatment  the  author  is  able  to 
bear  witness  from  personal  experience.  Some  two  or  three 
years  ago  he  was  called  in  consultation  to  a  number  of  cases  of 
diphtheria,  sometimes  to  several  in  a  single  day.  In  all  of  them 
the  use  of  the  spray  of  diluted  sulphurous  acid  water,  as  recom- 
mended by  Dewar,  applied  frequently  to  the  parts,  did  good  ser- 
vice. In  some  of  these  cases,  or  in  others  which  had  occurred  in 
the  same  families,  pencillings  with  nitrate  of  silver,  carbolic 
acid,  muriatic  acid,  and  other  remedies  had  proved  unavailing. 
In  one  family,  in  which  three  children  had  been  lost  in  the 
space  of  a  week  before  my  co-operation  had  been  invited,  we  had 
the  pleasure  of  saving  two  others,  one  of  whom  was  attacked 
while  in  attendance  upon  the  fourth  case,  which  was  said  to  be 
in  all  respects  as  unfavorable,  when  I  first  saw  it,  as  the  fatal 
cases  had  been  at  the  same  period  of  the  disease. 

The  treatment  consisted,  in  the  instances  referred  to,  in  placing 
the  patient  in  bed  in  a  room  warmed  by  fire,  with  a  vessel  of 
water  on  the  fire  to  keep  up  a  gentle  evolution  of  steam.  The 
spray  of  sulphurous  acid  water  was  projected  into  the  mouth  and 
pharynx  from  a  steam  apparatus  every  two  or  three  hours,  for 
about  ten  minutes  at  a  time.  Eggnog  and  beef -tea  were  given 
freely  as  nourishment.    Quinine  and  the  tincture  of  the  chloride 


102  DIPHTHEEIA. 

of  iron  were  administered  four  times  a  day  in  full  doses;  and 
lozenges  of  chlorate  of  potassa  were  allowed  to  dissolve  in  the 
mouth  ad  libitum,  each  lozenge  containing  one  grain  of  the  salt. 

I  found  the  use  of  the  sulphurous  acid  spray  to  do  more  good 
than  the  vapors  of  lime,  which  I  had  already  used  in  previous 
cases,  and  which  had  been  resorted  to  unavailingly  in  several  of 
the  cases  visited  at  that  time. 

As  far,  then,  as  my  own  limited  observation  goes,  it  is  in  favor 
of  the  use  of  sulphur. 

By  means  of  a  hand-ball  apparatus,  with  a  long  tube,  the 
spray  can  be  projected  into  the  nostrils  and  up  behind  the  palate. 
Where  there  is  the  slightest  evidence  of  approaching  implica- 
tion of  the  nares,  these  cavities  should  be  washed  with  the  sul- 
phurous spray,  or  with  a  solution  of  alum.  It  would  not  be  bad 
practice  to  cleanse  them  out  once  or  twice  a  day  in  every  in- 
stance. 

The  curative  powers  of  the  hyposulphite  of  soda  in  diphtheria, 
first  suggested  by  Dr.  Tubbs,  of  Upwell,'  employed  both  lo- 
cally and  internally,  is  doubtless  due  to  the  influence  of  the  sul- 
phurous acid  ;  and  this  may  be  resorted  to  under  circumstances 
where  sulphurous  acid  cannot  be  readily  obtained.  The  local 
treatment  consists  of  two  applications  daily  of  three  drachms  of 
the  salt  in  an  ounce  of  a  mixture  composed  of  two  parts  of  glycer- 
ine and  six  of  water ;  in  addition  to  which  a  gargle  is  used  every 
hour,  containing  half  a  drachm  of  the  hyposulphite  to  half  a 
pint  of  water,  with  half  an  ounce  of  glycerine.  It  is  better  to 
wash  the  parts  by  means  of  a  syringe.  The  hyposulphite  is  ad- 
ministered internally  in  doses  of  from  one  to  three  grains  to 
children,  and  eight  to  ten  grains  to  adults,  and  repeated  every 
four  hours. 

When  flowers  of  sulphur  are  used,  they  can  be  blown  upon 
the  parts,  or  placed  upon  them  by  means  of  a  moistened  mop  ; 
and  this  contact  is  renewed  as  soon  as  the  previous  application 
has  disappeared  from  them.  At  the  same  time  sulphm-  is  ad- 
ministered internally  in  frequent  doses,  and  also  used  in  gum- 
arabic  water  as  a  wash  or  gargle. 

1  Med.  Times  and  Qaz.,  Dec.  30,  1865. 


DIPHTHEEIA.  103 

The  blood-poisoning  nature  of  diphtheria  is  evident  from  the 
serious  effects  which  sometimes  follow  after  the  patient  has  re- 
covered from  the  disease.  There  are,  as  already  mentioned, 
certain  disturbances  of  accommodation  and  other  defects  of 
vision ;  paralysis  not  only  of  the  muscles  of  deglutition,  but  some- 
times of  other  muscles,  and  occasionally  general  paralysis. 

ISTourishing  food,  fresh  air,  and  general  tonics  usually  effect 
the  gradual  subsidence  of  these  symptoms  ;  and  when  obstinate, 
the  employment  of  electricity  is  an  effective  remedy  for  the 
local  paralyses. 

The  question  of  the  performance  of  tracheotomy  will  some- 
times come  up,  in  cases  where  the  larynx  is  being  invaded  by 
the  false  membrane.  The  operation  is  less  promising  of  success 
in  diphtheria  than  in  croup.  Before  any  operation  of  this  kind 
is  instituted,  it  will  be  well,  when  at  all  practicable,  to  become 
assured,  by  laryngoscopic  examination,  that  the  symptoms  of 
suffocation  seeming  to  call  for  the  operation  are  really  due  to 
mechanical  obstruction.  The  tendency  of  the  lips  of  the  wound 
to  become  covered  with  the  diphtheritic  deposit  should  be  com- 
bated by  whatever  means  may  have  proved  efficacious  in  affect- 
ing the  deposit  in  the  throat.  Nourishment  and  stimulation  are 
fully  as  necessary  after  the  operation  as  before  it,  if  not  more  so. 


104      SOEE  THEOATS  OF  THE  EXANTHEMATA. 


CHAPTEE    V. 

THE    SOEE    THEOATS    OF    THE    EXAIS^THEMATA. 

The  Sore  Throat  of  Small-Pox. — The  throat  is  liable  to  be 
affected  in  small-pox,  an  eruption  forming  upon  the  mucous 
membrane  similar  to  that  appearing  on  the  skin.  The  involve- 
ment of  the  throat  is  usually  indicated  by  excessive  salivation ; 
the  secretion  increases  gradually  in  quantity,  and  becomes  more 
and  more  viscid.  If  the  larynx  is  involved,  as  happens  not  in- 
frequently, there  will  be  more  or  less  hoarseness  of  voice  and 
other  concomitant  symptoms  of  extension  of  the  inflammation 
into  the  larynx.  This  inflammation  may  prove  fatal  by  oedema, 
which  may  even  occupy  a  position  beneatli  the  glottis,  a  speci- 
men of  which  condition  is  preserved  in  St.  Thomas's  Museum.' 
The  existence  of  pustules  upon  the  inside  of  the  cheeks,  on  the 
uvula,  palate,  and  pharynx,  is  well  known ;  they  have  often  been 
seen  occupying  these  situations. 

Since  the  introduction  of  the  laryngoscope  into  medical  use, 
small-pox  pustules  have  been  frequently  seen  in  the  larynx  dur- 
ing the  progress  of  the  disease.  That  the  larynx  was  sometimes 
invaded  was,  however,  well  knowm  before  the  days  of  laryngos- 
copy, for  the  evidences  of  the  existence  of  variolous  pustules 
in  the  larynx,  below  the  glottis  as  well  as  above  it,  have  been 
found  in  the  post-mortem  examinations  of  persons  dead  of  the 
disease. 

The  appearance  of  variolous  pustules,  as  seen  in  the  larynx, 
has  been  depicted  by  Tiirck,  who  describes  ^  a  case  of  small-pox 
in  the  adult,  in  which  hoarseness  occurred  on  the  tenth  or  elev- 
enth day  of  the  disease.     Two  or  three  days  after,  he  made  a 


'  Gibb,  Oil  Diseases  of  the  Throat  and  Windpipe^  2d  ed. ,  p.  219. 
*  Klinik  der  Krankheiten  des  Kehlkopfes  und  der  Luftrohre.     Vienna,  18G6, 
p.  180. 


SOEE  THROAT  OF  SMALL-POX.  105 

laryngoscopic  examination  of  the  larynx,  and  discovered  a  vari- 
olous pustule,  surrounded  with  an  inflamed  areola,  upon  the 
upper  surface  of  the  anterior  portion  of  the  left  vocal  cord,  and 
two  others  upon  the  posterior  laryngeal  wall,  in  front  of  the 
transverse  arytenoid  muscle.  I  have  seen  them  upon  the  epi- 
glottis, aryteno-epiglottic  folds,  and  upon  the  ventricular  bands. 
In  one  case  of  acute  laryngitis  accompanying  a  very  severe  case 
of  distinct  small-pox,  aphonia  occurred  suddenly  on  the  eleventh 
day,  without  having  been  preceded  by  hoarseness.  In  order  to 
determine  the  influence  that  the  trouble  in  the  throat  might 
have  on  the  prognosis  of  the  case,  I  was  asked  to  examine  the 
case  on  the  fifteenth  day,  and  found  that  the  aphonia  was  due 
to  paralysis  of  the  arytenoid  muscle.  Tlie  parts  in  the  neigh- 
borhood Avere  slightly  oedematous.  A  favorable  prognosis  re- 
moved the  doubts  of  the  parties,  and  was  verified  by  the  result. 
The  voice  gradually  returned  during  the  convalescence  of  the 
patient. 

In  cases  of  confluent  small-pox  the  involvement  of  the  throat 
is  much  more  serious.  Here  the  symptoms  often  begin  on  the 
very  first  day  or  two  of  the  appearance  of  the  eruption  upon 
the  skin.  The  salivation  produced  may  be  very  profuse,  even 
amounting  to  one  or  two  pints  of  fluid  during  the  day,  a  quan- 
tity altogether  out  of  proportion  to  the  visible  amount  of  local 
trouble.  With  this  there  is  excessive  thirst,  more  or  less  difii- 
culty  of  swallowing,  and  more  or  less  pain  in  expectoration. 
The  participation  of  the  larynx  in  the  local  manifestation  of  the 
disease  is  distinguished  by  cough  and  more  or  less  hoarseness 
of  voice.  Sometimes  there  is  great  dyspnoea  from  oedematous 
swelling  of  the  aryteno-epiglottic  folds  and  other  structures  of 
the  larynx,  and  this  has  sometimes  resulted  in  fatal  suffocation. 
In  a  case  of  variola  terminating  fatally  in  this  way  by  suffoca- 
tion, M.  Bernutz  found,^  in  addition  to  marked  oedema  of  the 
aryteno-epiglottic  folds,  several  ulcerations  in  the  larynx  and 
trachea  which  had  destroyed  the  mucous  membrane,  and  one 
which  had  perforated  the  larynx. 

The  injuries  inflicted  upon  the  larynx  during  the  course  of  a 

1  Gas.  hebd.,  1868,  p.  790. 


106  SORE    THEOATS    OE   THE    EXAISTTHEMATA. 

case  of  confluent  small-pox  may  be  permanent.  In  one  or  two 
cases  examined  by  the  author,  years  after  the  attack  of  small- 
pox, the  larynx  appeared  in  a  state  of  chronic  inflammation, 
and  studded  with  permanently  enlarged  follicles.  There  were 
also  little  elevations  upon  the  surface  of  the  vocal  cords,  which 
were  quite  red.  The  symptoms  complained  of  by  the  patients 
were  constant  hoarseness,  without  pain  in  vocalization,  and  a 
frequent  subsidence  of  laryngeal  sound  on  exertion  of  the 
voice,  or  upon  exposure  to  cold,  sometimes  amounting  to  abso- 
lute aphonia,  lasting  from  a  period  of  several  hours,  or  a  day  or 
two,  to  several  days  or  a  few  weeks.  The  voice  in  these  cases, 
in  addition  to  its  hoarse  quality,  sounded  like  that  of  a  tired 
and  languid  convalescent,  feeble  and  hesitating,  as  though  the 
effort  to  produce  it  were  painful  and  exhausting.  Dr.  Gibb  ^ 
relates  a,n  interesting  case  in  which  one  vocal  cord  appeared  to 
have  been  destroyed  by  small-pox ;  and  another  in  which  the 
patient  had  been  the  subject  of  aphonia,  hoarseness,  and  chronic 
laryngeal  disease  for  thirty-eight  years  subsequent  to  an  attack 
of  small-pox.  The  ventricular  bands  were  very  much  swollen, 
and  one  of  them  had  a  small  abscess  upon  it  at  the  time  of  ex- 
amination. He  also  mentions  an  anatomical  preparation  from 
a  small-pox  case,  in  which  the  trachea  was  studded  with  distinct 
elevated  spots  of  coagulable  lymph,  like  the  pustules  of  small- 
pox. 

The  Sore  Throat  of  Measles. — The  sore  throat  of  measles 
is  a  catarrhal  affection  of  the  air-passages,  including  the  nostrils, 
throat,  larynx,  and  more  or  less  of  the  bronchial  tract ;  a  more 
or  less  painful  coryza  and  laryngitis  therefore,  the  effect  of 
which  is  propagated  along  the  lachrymal  duct,  producing  in- 
jection of  the  conjunctival  mucous  membrane,  intolerance  of 
light,  and  lachrymation.  The  secretions  are  viscid  and  acrid, 
inducing  spasms  of  sternutation,  sometimes  attended  by  rup- 
ture of  the  blood-vessels  producing  an  epistaxis.  The  Eusta- 
chian tubes  sometimes  become  involved  in  the  catarrhal  inflam- 


^  On  Diseases  of  the  Throat.     London,  1864 ;  p.  386. 


SOEE    THEOAT    OF    SCAELATINA.  107 

mation  of  measles,  and  we  may  have  merely  moderate  deafness, 
or  even  marked  deafness  accompanied  by  acute  pain  in  the  ears. 

The  mucous  membranes  of  the  throat  are  often  affected  before 
there  is  any  manifestation  of  the  disease  on  the  cutaneous  sur- 
face ;  and  in  some  instances  evidences  of  the  eruption  will  -^be 
found  upon  the  palate  a  day  or  more  in  advance  of  its  appear- 
ance upon  the  skin ;  and  from  its  appearance  upon  tlie  palate 
it  can  sometimes  be  defined  upon  the  tonsils  and  pharynx  before 
it  is  seen  on  the  external  surface. 

In  cases  of  severe  sore  throat  attending  measles,  a  mem- 
branous exudation  is  sometimes  thrown  out  upon  some  portion 
of  the  palate  or  pharynx,  and  on  the  upper  portion  of  the 
larynx.  It  is  less  fibrinous  than  the  false  membrane  of  croup 
and  diphtheria,  more  liable  to  disintegration,  and  less  equably 
distributed  upon  the  surface. 

The  larynx  seems  to  bear  the  brunt  of  the  throat  complica- 
tion in  measles,  and  in  some  instances  the  catarrhal  laryngitis  is 
extremely  severe,  hoarseness  of  voice  persisting,  from  chronic 
inflammation  of  the  vocal  cords  and  other  intralaryngeal  struc- 
tures, for  a  long  time  after  subsidence  of  the  original  affection. 
Occasionally  the  catarrhal  condition  predisposes  the  parts  to  the 
production  of  papillomatous  excrescences  within  the  larynx, 
principally  upon  the  vocal  cords,  or  in  the  ventricles,  tlie  same 
localities  in  which  we  find  them  after  membranous  croup  ;  and 
these  may  be  so  extensive  as  to  demand  surgical  interference, 
otherwise,  as  in  one  case  which  came  under  the  author's  obser- 
vation, they  may  prove  fatal  by  suffocating  the  patient. 

The  Sore  Throat  of  Scarlatina. — The  sore  throat  of  scar- 
latina is,  in  some  instances,  the  most  important  source  of  danger 
in  the  progress  of  the  disease,  some  of  the  varieties  of  which 
have  been  given  names  specially  designating  the  anginose  and 
malignant  complications. 

In  the  sore  throat  of  scarlatina,  the  palate  and  pharynx  seem 
to  bear  the  brunt  of  the  affection,  which  is  often  propagated 
along  the  Eustachian  tubes  into  the  middle  ear,  producing  de- 
structive inflammation  of  more  or  less  of  the  structures  in  that 
locality.     The  cases  of  chronic  sore  throat,  chronic  deafness, 


108      SOEE  THKOATS  OF  THE  EXANTHEMATA. 

and  chronic  otorrhoea  ^\^liicli  have  had  their  origin  in  the  sore 
throat  of  scarlatina  are  very  numerous.  The  nasal  passages  are 
not  often  invaded  in  scarlatina,  and  the  larynx  very  rarely  indeed. 

Some  amount  of  sore  throat  is  present  in  every  case  of  scar- 
latina ;  indeed,  there  is  reason  to  believe  that  there  are  some 
very  mild  cases  in  which  the  sore  throat  is  the  only  manifesta- 
tion of  the  disease.  It  is  known  that  some  physicians  subject  to 
sore  throat  are  almost  certain  to  acquire  an  accession  of  their 
complaint  while  in  attendance  upon  scarlatinous  cases. 

The  sore  throat  of  scarlatina,  like  that  of  measles,  sometimes 
precedes  the  cutaneous  manifestation.  If  seen  early  in  the 
attack,  the  mucous  tissues  of  the  pharynx,  in  a  case  of  scarlatina 
simplex,  will  be  of  a  deep-red  color,  the  palate  will  be  swollen, 
as  also  the  tonsils,  w^hich  will  exhibit  a  hue  still  darker  than 
that  of  the  surrounding  structures.  A  day  or  two  later,  there 
will  be  found  an  opalescent  or  milky  accretion  upon  the  ton- 
sils, presenting  some  resemblance  to  the  false  membrane  of 
diphtheria,  but  differing  in  color,  consistence,  and  physical 
characteristics.  It  is  supposed  to  consist  of  an  intermingling 
of  detached  epithelium  entangled  in  an  excess  of  the  viscid 
secretion  so  often  furnished  by  the  tonsils  in  ordinary  inflam- 
mations. It  is  the  production  of  this  coating  which  has  caused 
some  practitioners  to  contend  for  an  analogy  between  scarlatina 
and  diphtheria.  But  other  than  the  mere  fact  of  their  occa- 
sionally simultaneous  prevalence,  there  is  no  evidence  at  all  of 
relationship.  Still,  during  an  epidemic  of  diphtheria,  the  sore 
thi'oat  of  scarlatina  may  become  diphtheritic,  but  not  as  an 
essential  element  of  the  scarlatinous  affection. 

As  the  disease  progresses,  the  throat  symptoms  become  more 
and  more  severe,  and  the  cervical  glands  at  the  angle  of  the 
jaw  become  swollen  and  painful.  With  this,  sometimes,  the 
inflammation  is  attended  with  effusion  into  the  submucous 
connective  tissue,  and  thus  is  produced  more  or  less  impediment 
to  respiration  and  deglutition,  but  especially  the  latter ;  fluids, 
in  swallowing  them,  often  returning  by  the  nostrils.  As  the 
violence  of  the  cutaneous  symptoms  abate,  so  do  those  of  the 
throat  moderate.  The  tonsils  cast  off  their  adherent  secretion, 
exhibiting  a  red  and  sometimes  raw  surface  beneath  ;  the  red- 


SOEE    THROAT    OF    SCAKL  A.TINA.  109 

ness  of  the  parts  diminislies,  and  the  swellings  subside.  Some- 
times there  is  a  desquamation  of  an  epitlielial  layer  from  the 
tongue  and  pharynx,  similar  to  the  desquamation  which  takes 
j)laee  from  the  skin. 

In  the  anginose  variety  of  scarlatina  the  throat  symptoms 
are  more  severe  than  those  already  narrated.  The  hue  of  the 
palate  and  pharynx  will  be  more  dusky,  the  color  of  the  mem- 
branous secretion  of  a  dirtier  white,  ash,  or  even  yellowish 
color,  and  it  will  not  be  so  apt  to  be  confiiied  to  the  tonsils,  but 
will  accumulate  upon  the  palate  and  its  arches,  and  ujDon  the 
posterior  wall  of  the  pharynx,  sometimes  as  far  down  as  this 
structure  can  be  exposed  to  view.  These  patches  are  soft,  and 
easily  removed,  and  resemble  very  much  in  appearance  the  ca- 
coplasma  that  is  seen  on  the  surface  of  foul  ulcers ;  and  when 
removed  sometimes  really  do  reveal  ulcerated  and  even  gan- 
grenous destruction  of  mucous  membrane  beneath  them.  The 
swelling  of  tonsils,  palate,  and  pharynx  is  much  greater  than 
that  met  with  in  scarlatina  simplex ;  and  so  is  the  tumefaction 
of  the  cervical  and  submaxillary  glands,  which  is  sometimes  so 
firm  and  painful  as  to  prevent  the  patient  from  properly  open 
ing  the  mouth  so  as  to  expose  the  parts  to  inspection. 

There  is  an  accumulation  of  viscid  secretion  in  the  mouth 
similar  to  that  seen  in  measles,  and  likewise  painful  to  expec- 
torate. Like  in  measles,  too,  the  nasal  passages  may  become 
implicated  in  the  disease ;  and  the  nasal  secretions  condense  into 
hard  crusts  which  obstruct  the  passage  of  the  air,  and  compel 
the  patient  to  keep  the  mouth  opened.  As  the  disease  pro- 
gresses, an  acrid,  offensive,  yellow-colored  secretion  is  poured 
out  fi-om  the  nostrils,  sometimes  excoriating  them  in  its  pas- 
sage ;  and  the  secretions  fi'om  the  mouth  assume  at  the  same 
time  a  similar  character.  The  symptoms  of  inflammation  of 
the  Eustachian  tube  are  likewise  increased  in  severity. 

In  scarlatina  maligna  the  sore  throat  is  of  that  character  de- 
scribed as  malignant,  and  this  form  may  commence  from  the 
outset,  or  ensue  upon  a  case  of  anginose  or  even  simple  scarla- 
tina, even  after  a  period  of  apparent  convalescence  has  become 
established.  It  is  the  knowledge  of  this  liability  to  become 
malignant  that  renders  physicians  so  cautious  about  committing 


110      SOEE  THROATS  OF  THE  EXANTHEMATA. 

themselves  with  regard  to  the  prognosis  in  any  case  of  scarlet 
fever,  however  mild  it  may  be.  In  addition  to  an  increase  in 
the  severity  of  the  symptoins  of  sore  throat  described  as  accom- 
panying scarlatina  anginosa,  there  will  be  those  peculiar  consti- 
tutional symptoms  which  are  designated  as  typhoid.  The  mu 
cous  membrane  of  the  throat  is  very  much  swollen,  of  a  very 
dark- red  or  purple  color;  there  are  ulcerations,  fi-equently  of  a 
gangrenous  character,  penetrating  the  tissue  of  the  mucous 
membrane ;  the  membranous  deposit  is  much  darker  in  color, 
almost  black,  and  intermingled  with  extra vasated  blood.  The 
discharges  are  extremely  offensive,  and  are  sanious  in  character, 
and  not  infrequently  mingled  with  the  products  of  hemorrhage 
from  some  portion  of  the  mucous  membrane. 

The  swellings  at  the  angles  of  the  jaw  increase  and  extend  to 
the  neck,  and  so  does  the  tumefaction  internally,  so  that  deglu- 
tition becomes  impossible,  and  respiration  occasionally  impeded 
to  that  extent  as  to  demand  tracheotomy  in  rescue  from  im- 
pending suffocation — an  operation  which  may  also  become  ne- 
cessary on  account  of  oedema  of  the  aryteno-epiglottic  folds 
of  the  larynx,  or  of  oedema  of  the  epiglottis — manifestations 
which  sometimes  occur  in  connection  with  oedema  of  the  uvula 
and  soft  palate,  as  an  expression  of  the  general  condition  of 
anasarca  which  attends  scarlatina  as  one  of  its  sequelae. 

The  treatment  of  the  sore  throat  of  scarlatina  wdll,  in  the 
main,  be  similar  to  that  for  the  treatment  of  ordinary  inflam- 
matory sore  throat,  save  that  the  application  of  severe  remedies 
is  rarely  called  for.  The  use  of  sprays  propelled  into  the 
mouth  and  upon  the  affected  parts  will  prove  of  great  etHcacy, 
and  can  be  employed  under  circumstances  in  which  the  mop 
and  the  gargle  cannot  be  resorted  to.  A  weak  solution  of  alum 
is  recommended,  with  the  use  of  detergents,  when  indicated. 

ERYSIPELATOUS    SOKE    THROAT. 

Erysipelas  occasionally  attacks  the  throat  as  an  extension  of 
erysipelas  of  the  head  and  face ;  and  in  some  instances  appears  to 
begin  in  the  throat  and  spread  thence  to  the  exterior.  When  the 
throat  is  involved  there  is  imminent  danger  of  implication  of  the 
larynx,  with  the  production  of  cedema. 


ERYSIPELATOUS    SOEE   THROAT.  Ill 

Sometimes,  however,  as  graphically  narrated  by  Prof.  Todd,^ 
an  idiopathic  erysipelas  occurs  in  the  throat  which  is  confined  to 
■the  pharynx.  The  anthor  has  never  seen  a  case  of  the  kind. 
Several  instances  of  this  affection  are  given  by  Dr.  Todd,  who 
describes  them  as  running  their  course  towards  death  or  recovery 
within  f  ortv-eiffht  hours.  The  attack  usually  commences  with  a 
catarrh  ;  and  the  principal  symptoms  are  a  clusky-red  hue  of  the 
pharynx,  with  inability  to  swallow ;  and  this  inability  does  not 
proceed  from  swelling  but  from  actual  paralysis,  it  being  impos- 
sible to  excite  the  pharyngeal  muscles  to  contraction  even  by  the 
contact  of  the  finger  or  instruments.  The  regurgitation  takes 
place  chiefly  through  the  mouth.  The  treatment  recommended 
consists  in  touching  the  parts  lightly  with  the  solid  nitrate  of 
silver,  or  freely  washing  them  with  a  strong  solution  of  the 
same ;  and  in  the  frequent  injection  of  enemas  of  beef -tea  con- 
taining large  doses  (10  grains)  of  quinine.  Improvement  usually 
begins  in  from  twenty-four  to  forty-eight  hours,  and  as  soon  as 
the  power  of  deglutition  commences  to  return,  frequent  and 
large  doses  of  brandy,  ammonia,  chloric  ether,  and  beef -tea  are 
given  by  the  mouth. 

A  case  of  pharyngeal  erysipelas  making  its  way  on  the  face 
through  the  lachrj'mal  canal  has  been  recorded^  by  M.  Gallard. 
A  female,  twenty -five  years  of  age,  was  taken  ill,  March  13th,  with 
chill,  fever,  pain  in  the  throat,  difficulty  in  swallowing,  and  great 
swelling  of  the  glands  of  the  neck  and  of  the  lower  jaw.  The 
symptoms  increased  until  the  17th,  when  the  pain  in  the  throat 
subsided,  but  was  followed  by  burning  pain  in  the  nostrils.  On 
the  18th  there  was  pain  at  the  inner  angle  of  the  right  eye,  with 
redness  and  swelling  of  the  lower  lid,  which  in  the  course  of  the 
day  continued  along  the  naso-labial  sulcus  and  extended  to  the 
line  of  the  border  of  the  jaw;  these  symptoms  being  attended 
with  severe  fever  and  repeated  vomiting.  On  the  20th  there  was 
redness  and  swelling  of  the  left  cheek  commencing  over  the 
inner  eyelid ;  and  the  mucous  membrane  of  the  pharynx  was 
only  still  much  injected.     The  erysipelas  spread  from  the  nose 


'  Clinical  Lectures  on  Cerfcaia  Acute  Diseases,  PhUa.  Ed.  1860,  p.  151. 
'  {Gaz.  lies  hop.Al,  1868)  Schmidt's  Jahrb.,  Jan,,  1869,  p.  35. 


112  ERYSIPELATOUS    SOEE    THEOAT. 

and  chin,  and  united  upon  the  forehead  on  the  22d,  whence 
it  extended  over  the  anterior  third  of  the  hairy  scalp,  and  formed 
blisters  here  and  there,  and  on  the  next  day  redness  and  swell- 
ing disappeared  for  the  first  time  from  the  right  cheek,  and  on 
the  following  days  from  the  other  portions.  On  the  29th  the 
patient  was  well. 

Another  case  was  reported^  by  Rigal,  in  which  the  erysipelas 
of  the  pharynx  extended  into  the  nasal  passages,  and  thence 
over  the  conjunctivae  and  the  face. 

»  Gaz.  des  hop.,  1869,  20. 


SYPHILITIC    SORE    THROAT.  113 


CHAPTEE    VI. 

SYPHILITIC    SORE    THROAT. 

This  affection  is  very  common  in  every  large  coramunitj, 
usually  as  a  symptomatic  manifestation  of  systemic  poisoning 
produced  in  the  usual  way  ;  but  sometimes  the  result  of  direct 
poisoning  from  chancres  about  the  lips,  tongue,  and  hard  palate, 
produced  by  actual  contact.  Secondary  symptoms  are  some- 
times communicated  by  the  kisses  or  bites  of  infected  indi- 
viduals ;  they  have  been  known  to  follow  the  drawing  out  of 
the  nipple  of  the  parturient  female,  by  suction  with  the  mouth 
of  a  syphilitic  nurse.  In  children  it  is  sometimes  contracted 
from  the  nipple  of  the  nurse.  Some  observers  have  thought 
that  it  could  be  communicated  to  the  mouth  of  the  infant 
through  the  medium  of  the  milk,  but  it  must  be  exceedingly 
doubtful  that  infection  is  evei*  bi'ought  about  in  this  way.  It 
is  also  occasionally  propagated  by  the  use  of  certain  instruments 
placed  in  the  mouth,  such  as  the  blowpipe,  trumpet,  etc.  I  have 
known  it  to  be  connnunicated  by  the  incautious  use  of  the  Eus- 
tachian cathetei',  a.  fearful  case  of  i-avage  from  which  was  shown 
to  me  several  years  ago  by  my  friend  Dr.  R.  J.  Levis,  of  Phila- 
delphia. 

The  chancre  met  with  on  the  lip  and  tongue  is  usually  of  the 
hard  variety;  still,  soft  chancre  is  also  encountered,  and  I  have 
seen  cases  where,  both  lips  and  tongue  being  involved,  a  consider- 
able portion  of  the  latter  organ  was  the  subject  of  extensive 
phagedenic  ulceration,  presenting  a  most  horrible  and  disgusting 
spectacle. 

The  only  affections  with  which  chancre  in  the  lips  and  tongue 
could  be  confounded  are,  perhaps,  epithelioma  and  furuncle  ;  but 
the  appearances  of  the  latter  are  so  characteristic  that,  taken  in 
connection  with  the  sort  of  individual  likely  to  be  the  subject  of 
chancre  about  tlie  mouth,  a  mistake  in  diagnosis  is  hardly  pos- 
sible. These  cases  are  not  seen  early  as  a  usual  thing ;  for  shame 
on  the  one  hand,  and  ignorance  on  the  other,  are  likely  to  deter 
the  patients  from  applying  for  medical  treatment  until  they  find 


114  SYPHILITIC    SORE    THEOAT. 

it  absolutely  necessary,  in  order  to  control  the  ravages  of  the 
disease. 

Syphilitic  diseases  of  the  throat  are  much  more  likely  to 
appear  as  manifestations  of  secondary  and  tertiary  syphilis, 
though  the  characteristics  of  the  two  forms  are  not  as  well  de- 
fined as  when  occurring  in  other  parts  of  the  body.  Where 
the  former  existence  of  a  primarj^  affection  is  acknowledged, 
the  duration  of  the  affection  will  be  an  important  element  in 
the  discrimination,  as  also  the  evidence  of  syphilitic  disease  in 
the  skin ;  the  usual  period  for  secondary  manifestations  being 
from  four  to  eight  weeks  from  the  date  of  infection.  Of  these 
syphilitic  affections  of  the  throat,  some  are  similar  to  those  met 
with  on  the  cutaneous  surface,  and  others  are  peculiar  to  the 
mucous  membrane. 

The  most  frequent  seat  of  syphilitic  inflammation  of  the 
throat  is,  perhaps,  the  soft  palate ;  beginning  usually  near  the 
border  of  the  hard  palate  and  spreading  downwards  upon  either 
side,  though  sometimes  travelling  along  the  hard  palate  also. 
We  do  not  often  see  separate  blotches  such  as  are  observed 
upon  tlie  skin,  but  rather  a  diffused  redness  without  any  dis- 
tinct line  of  demarcation.  This  erythematous  condition  gradu- 
ally extends  to  the  arches  of  the  palate,  and  presents  the  ap- 
pearances of  ordinary  inflammation.  Sometimes  it  is  distributed 
in  irregular  patches,  separated  by  healthy-looking  membrane. 
Should  the  disease  not  have  been  arrested  at  this  stage,  there 
ensues  a  swelling  of  the  affected  parts,  with  a  gradual  change  to 
a  livid  color.  The  movements  of  the  palate  become  impeded 
by  the  interstitial  deposit  going  on  in  its  tissues,  occasionally 
amounting  to  complete  paralysis.  The  tonsils  are  very  apt  to  be 
involved,  becoming  somewhat  swollen,  though  not  often  mark- 
edly so ;  but  they  are  red,  hard,  irregular  in  outline,  and  soon 
become  covered  with  a  pasty  secretion  that  often  adheres  in 
strands  to  their  lacunae.  These  hypertrophied  tonsils  are 
sometimes  the  seat  of  condylomata,  and  if  careful  investigation 
be  made,  the  coexistence  of  similar  vegetations  elsewhere  will 
often  be  revealed.  The  follicular  glands  of  the  palate  and 
uvula  become  enlarged  and  prominent,  and  the  uvula  often 
markedly  osderaatous. 


SYPHILITIC    SOEE    THEOAT.  115 

Should  the  progress  of  the  disease  not  be  arrested  in  this 
stage,  the  inflamed  follicles  of  the  palate  and  of  the  tonsils 
nlcerate  ;  and  the  ulcers  run  into  each  other  and  often  extend 
rapidly,  the  gums,  tongue,  and  epiglottis  sometimes  partici- 
pating. These  ulcers  are  soft,  co^^-ered  with  grayish  aplastic 
deposit,  sometimes  pellicular,  and  are  usually  excavated,  with 
sharp  edges,  and  surrounded  by  a  demarcating  border  of  red- 
dened membrane.  They  are  at  first  superficial,  but  soon  in- 
volve the  entire  mucous  membrane  and  penetrate  into  the  sub- 
mucous tissue.  Sometimes  al)scesses  form,  principally  in  the 
palate,  and  in  the  tonsils  and  palatine  folds :  and  these  finally 
discharge,  leaving  foul  ulcers,  chiefly  at  the  root  of  the  uvula, 
which  is  sometimes  destroyed  in  the  ulcerative  process ;  but 
they  also  occur  in  other  portions,  and  often  penetrate  the  entire 
thickness  of  the  palate  in  their  ulcerative  ravages ;  sometimes 
in  its  central  portion,  sometimes  to  one  side  or  the  other,  and 
not  infrequently  comparatively  large  portions  of  the  arches 
are  destroyed  in  consequence.  This  destructive  process  some- 
times proceeds  with  great  rapidity,  a  period  of  twenty-four  or 
forty-eight  hours  sufficing  to  complete  the  perforation.  The 
ulcerated  tonsils  bleed  readily  to  the  touch,  and  may  undergo 
entire  destruction.  During  this  time  the  pharynx  becomes 
equally  involved ;  in  many  instances  ulceration  being  pro- 
duced, so  that  very  often  there  is  formed,  in  cicatrization, 
an  adhesion  between  the  sides  of  the  palate,  or  its  posterior 
arch,  and  the  wall  of  the  pharynx.  The  ulcerative  process 
sometimes  extends  to  the  cervical  vertebrse,  and  produces  ex- 
foliation of  dead  bone.  The  tongue,  gums,  lips,  and  cheeks 
also  participate  in  the  affection,  so  that  there  is  ulceration  of 
all  these  parts  at  once,  or  in  prompt  succession.  From  the 
pharynx,  or  from  the  posterior  poi'tion  of  the  velum,  the  dis- 
eased process  extends  to  the  orifices  of  the  Eustachian  tubes, 
and,  not  infrequently,  continues  along  the  tube  into  the  tym- 
panum. The  inflammation  thus  excited  may  even  be  propagated 
to  the  inter-cranial  tissues  proper ;  though  more  frequently  rup- 
ture of  the  membrana  tympani  ensues,  giving  vent  to  discharges 
of  purulent  matters  through  the  external  ear.  The  mucous 
membrane  of  the  nose  is  also  attacked,  and  may  implicate  the 


116  SYPHILITIC    SOKE    THROAT. 

nasal  duct  producing  specific  inflammation  of  the  conjunctiTal 
mucous  membrane  ;  and  the  disease  in  many  instances  extends 
to  the  larynx,  which  is  also  often  affected  primarily.  The 
affection  of  the  nasal  mucous  membrane  may  extend  to  the 
bones,  and  produce  caries  and  necrosis.  Sometimes  the  disease 
of  the  bones  precedes  the  implication  of  the  mucous  meml^rane. 

The  larynx  becomes  involved  by  extension  of  the  disease 
from  the  anterior  arches  of  the  palate  usually,  and  all  the  phe- 
nomena of  syphilitic  inflammation  may  ensue,  leading  to  exten- 
sive ulceration  and  destruction.  The  epiglottis  is  quite  prone , 
to  suffer ;  and  there  may  be  great  loss  of  its  substance,  or 
even  entire  loss  of  it.  The  syphilitic  ulcerative  process  at- 
tacks the  aryteno-epiglottic  folds,  the  ventricular  bands,  and 
the  vocal  cords ;  sometimes  singly,  sometimes  together.  This 
ulceration  may  extend  to  the  cartilages,  and  produce  their  de- 
struction; or  the  disease  may  begin  in  syphilitic  perichondritis 
or  chondritis,  and  affect  the  mucous  membrane  in  the  exfolia- 
tion of  the  sequester.  Large  portions  of  cartilage  are  some- 
times destroyed,  and  even  entire  cartilages.  During  this  process, 
oedema  of  the  larynx  is  very  apt  to  take  place.  The  cicatriza- 
tion of  laryngeal  ulcers  often  produces  permanent  constriction  of 
the  laryngeal  oriflce,  and  sometimes,  even  if  the  glottis  is  not 
directly  implicated,  necessitates  the  operation  of  tracheotomy, 
with  almost  always  the  permanent  use  of  the  canule. 

The  trachea  also  is  liable  to  the  manifestations  of  syphilis ; 
and  the  ulcerative  process  may  involve  its  cartilages  as  well  as 
its  mucous  membrane. 

Syphilitic  warts  and  excrescences  are  liable  to  form  in  the 
larynx.  They  are  frequently  small,  multiple,  and  adherent  by 
a  broad  base ;  but  they  may  acquire  the  size  of  a  hickory-nut, 
almost  filling  up  the  upper  cavity  of  the  larjnix.  Sometimes 
they  are  flat  bands  hanging  into  the  glottis,  or  from  the  vocal 
cords.     They  may  occupy  any  portion  of  the  larynx. 

There  is  nothing  absolutely  characteristic  in  the  appearance 
of  syphilitic  disease  of  the  larynx,  whether  of  the  simple  erythe- 
matous form,  or  of  the  ulcerative  variety.  An  obstinate  chronic 
laryngitis  in  a  constitution  undoubtedly  free  from  tuberculous 
disease  of  the  lungs  is  almost  presumptive  evidence  of  its  sj'phi- 


SYPHILITIC    SORE    THROAT. 


117 


litlc  nature.  And  the  same  may  be  said  of  tlie  ulcerative  form, 
if  it  can  be  traced  to  no  otber  actual  cause.  There  are  some 
cases  which  simulate  cancer  in  their  appearance,  but  the  absence 
of  the  fancinating  pains  attending  malignant  disease  will  usually 
serve  to  eliminate  the  latter  from  the  diagnosis. 


Fig.  27. 


Syphilitic  ravages  in  the  soft  p  il  iti    t  ui^il,  and  lateral  pharyngeal  wall. 


Fig.  9«. 


Syphilitic  ravages  in  epiglottis,  and  lateral  laryngeal  wall,  in  same  case  as  Fig  27 


Sometimes,  however,  as  in  one  case  in  the  practice  of  the 
author,  and  delineated  in  Figs.  27  and  28,  the  disease  not  only 
simulates  ulcerative  epithelioma  in  its  appearances,  but  even  in 


118  SYPHILITIC    SOKE    THEOAT. 

the  lancinating  pains,  which,  in  the  instance  referred  to,  were 
constant,  mucli  more  constant  than  is  observed  in  cancer ; 
causing  the  patient,  a  man  aged  31  years,  to  twitch  his  head  to- 
wards tlie  side  affected  every  few  seconds  from  morning  until 
night,  whether  talking,  eating,  or  at  rest ;  and  this  for  weeks  to- 
gether ;  for  he  did  not  come  under  observation  until  a  late 
pei-iod  of  the  affection,  after  the  disease  had  committed  the 
ravages  depicted  in  the  illustrations,'  ravages  which  finally  de- 
stroyed the  entire  palate  and  ejDiglottis. 

The  mucous  tubercle,  as  it  is  called,  a  peculiar  affection  in  ir- 
regular elevations,  hard  to  the  touch,  resembling  in  appearance 
a  portion  of  surface  which  has  been  subjected  to  the  local  action 
of  nitrate  of  silver,  is  often  seen  upon  the  mucous  membrane  of 
the  throat.  It  is  thought  to  be  due  to  the  ulcerative  action  of  a 
gummy  deposit  which  has  existed  in  the  submucous  tissues.  It 
is  liable  to  produce  extensive  ulceration  and  destruction  of 
tissue.  Its  most  frequent  seat  is  the  tongue,  lips,  inside  of  the 
cheek,  and  the  soft  palate. 

The  treatment  of  consecutive  syphilitic  affections  of  the 
throat  is  very  simple,  and,  if  the  constitution  has  not  been  broken 
down,  usually  successful,  even  when  the  local  disease  is  very 
severe.  The  patient,  if  not  w^ell  nourished,  should  be  given 
wine,  iron,  and  quinine,  and  good  nutritious  diet,  until  his  gen- 
eral health  has  become  somewhat  re-established,  when  he  should 
be  placed  upon  specific  treatment.  This  will  consist,  usually, 
of  iodide  of  potassium ;  aided,  if  need  be,  by  the  bichloride  of 
mercury,  or  some  equivalent  mercnrial  preparation,  in  small 
doses.  Locally,  swabbing  the  parts  with  the  acid  nitrate  of 
mercury,  diluted  with  four,  ten,  or  twenty  parts  of  water,  as 
circumstances  may  indicate,  will  usually  be  found  fully  effi- 
cient as  a  topical  remedy.  If  oedema  be  present  the  parts  must 
be  scarified,  or  ruptured  by  compression ;  after  which  a  solution 
of  the  nitrate  of  silver  may  be  employed  upon  them.  Should 
the  oedema  recur,  it  must  be  treated  as  before.  Should  sjmip- 
toms  of  suffocation  supervene  which  cannot  be  subdued  by  less 

1  See  in  this  connection  a  case  of  inherited  syphilis  of  the  nose  simulating 
epithelioma.  Prof.  Gross'  Clinic,  May  37,  '11.  — The  Med.  Times,  Phila.,  July 
15th,  1871. 


SYPHILITIC    SOEE    THROAT    IN    INFANTS.  119 

severe  measures,  the  performance  of  tracheotomy  is  indicated. 
Astringent  applications  in  the  form  of  spray,  or  washes,  should 
be  freely  used  by  the  patient  if  there  be  a  great  deal  of  discom- 
fort from  swelling  and  inflammation  of  the  parts.  Fetor  is 
controlled  by  the  local  use  of  detergents  in  the  same  way. 

The  earlier  manifestations  of  syphilitic  sore  throat  usually  de- 
mand no  other  treatment  than  destruction  of  the  primary  ulcer- 
ation by  the  acid  nitrate  of  mercury  or  other  caustic,  followed 
by  such  treatment,  local  and  constitutional,  as  would  be  em- 
ployed in  non-specific  inflammatory  sore  throat. 

SYPHILITIC    SOKE    THROAT   IN   INFANTS. 

The  constitutional  manifestations  of  syphilis  in  the  throat  of 
the  infant  present  usually  in  the  form  of  mucous  patches. 
These  occupy  the  palate,  its  arches,  the  tonsils,  and  sometimes 
the  pharynx  ;  and  occasionally  tlie  larynx  also  seems  to  be  af- 
fected, judging  from  the  hoarseness  of  the  infant's  cry.  At  the 
same  time  the  mucous  tissues  of  the  mouth  may  be  impli- 
cated, such  as  the  gums,  lips,  tongue,  and  inside  of  the  cheek. 
Much  more  fi-equeutl}^,  however,  the  disease  manifests  itself  in 
the  form  of  a  coryza,  which  is,  probably,  in  accordance  with  the 
opinion  of  Diday  and  others,  due  to  the  development  of  mucous 
patches  upon  the  mucous  membrane  of  tlie  nose.  The  first  evi- 
dence of  the  disease  is  some  impediment  to  free  respiration 
by  the  nostrils,  and  consequent  embarrassment  in  taking  the  nip- 
ple ;  the  symptoms  being  similar  at  first  to  those  of  an  ordinary 
coryza.  After  a  short  time,  a  thin  serous  liquid  runs  from  the 
nose,  which  soon  becomes  thicker,  purulent,  and  somewhat  san- 
guinolent.  The  nose  becomes  more  and  more  stopped  up,  and 
as  this  condition  increases,  the  child,  while  suckling,  is  forced 
to  take  rapid  inspirations  through  the  nose,  which  dries  up  por- 
tions of  the  secretions  into  crusts,  which  are  discharged  with 
more  or  less  hemorrhage.  Finally  these  crusts  accumulate 
faster  than  they  can  be  discharged,  and  complete  obstruction  of 
the  nostrils  is  produced.  "When  this  is  the  case,  great  difliculty 
is  experienced  in  nourishing  the  child,  because  it  is  unable  to 
breathe  while  at  the  nipple.  It  seizes  the  breast  eagerly,  but  is 
compelled  to  let  it  go  again  almost  immediately,  which  renders 


120  SYPHILITIC    SOEE    THROAT. 

it  cross  and  fretful.  As  the  disease  progresses,  specific  pustules, 
fissures,  and  ulcers  form  ujDon  the  alse  of  the  nose  and  upon  the 
lips,  and  at  the  angles  of  the  mouth,  and  extend  outwards 
upon  the  cheek  along  the  natural  fissures  of  the  skin.  In  this 
manner,  sometimes,  peculiar  striated  appearances  are  produced, 
which,  according  to  Prof.  Trousseau,'  are  characteristic  of 
syphilis,  and  are  true  mucous  crusts,  though  not  exactly  of  the 
same  aspect  as  in  the  adult ;  their  size  being  smaller  the  greater 
their  distance  from  the  mucous  membrane  of  the  lips:  their 
edges  are  finely  fringed  and  blackened  by  the  adherence  of 
coagulated  blood  ;  and  they  have  gristly  and  bleeding  bottoms 
more  or  less  bright  red  in  color. 

Prof.  Trousseau  states  that  they  often  leave  indelil)le  cicatrices 
after  recovery,  and  that  he  has  seen  young  men  and  yoimg  wo- 
men still  carrying  these  cicatrices ;  stigmata,  the  nature  of  -svhich 
they  did  not  suspect. 

As  the  disease  of  the  nasal  passages  progresses,  ulceration 
takes  place  there  also,  and  it  often  destroys  the  cartilages  and  the 
bones,  fragments  of  which  are  thrown  off  with  the  crusts.  In 
this  way  the  septum  becomes  perforated,  and  the  nose  flat- 
tened. Sometimes  the  general  system  is  poisoned  by  the  exha- 
lations of  the  decomposing  secretions  in  the  nose,  and  death 
ensues  in  consequence.  This  sj^^hilitic  coryza  is  sometimes  the 
only  manifestation  of  hereditary  syphilis,  and,  according  to 
Trousseau,  the  earliest  sign  of  the  disease  in  almost  every 
instance. 

The  treatment  of  syphilitic  diseases  of  the  throat  in  the 
infant  does  not  differ  essentially  from  that  adopted  in  the 
treatment  of  syphilis  in  the  adult.  Care  must  be  taken  to  sus- 
tain the  nourishment  of  the  child  and  to  place  it  under  favor- 
able hygienic  influences.  To  this  end  a  healthy  wet-nurse  is  a 
great  desideratmn,  but  one  not  always  to  be  obtained.  It  i& 
stated  on  good  authority,  that  a  syphilitic  wet-nurse  is  admissi- 
ble provided  she  is  placed  under  specific  treatment,  that  is 
to  say,  mercurialized.  When  the  child  cannot  be  nursed,  the 
milk  of  the  goat,  the  ass,  or  the  cow  is  administered  by  the  bot- 

'   Clinical  Lectures.     Vol.  iv.     Sydenham  So.  Ed. 


SYPHILITIC    SOKE    THROAT    IN   INFANTS.  121 

tie  if  the  child  can  take  it,  otherwise  by  the  spoon,  the  same  as 
under  ordinary  circumstances.  The  child  should  be  kept  in  a 
warm  temperature,  be  clad  with  woollen  underclothing,  and 
great  care  should  be  taken  in  maintaining  cleanliness  of  the 
skin  and  in  prompt  removal  of  the  secretions.  Ablutions 
should  be  practised  more  frequently  than  with  the  healthy  in- 
fant. A  mercurial  course  appears  to  be  indispensable,  and  the 
best  article  for  this  purpose  is,  as  with  the  adult,  the  bichloride 
of  mercury,  which  may  be  given  in  solution  with  syrup,  in 
divided  doses,  varying  from  one  twelfth  of  a  grain  daily 
upwards  u.ntil  some  sign  of  inflammation  is  observable  upon  the 
gums,  or  until  the  characteristic  odor  is  perceptible  in  the 
breath,  when  the  quantity  of  the  mercurial  may  be  slightly 
diminished,  but  not  to  a  greater  extent  than  is  necessary 
to  keep  up  evidences  of  its  specific  effect.  The  mercurialization 
may  be  assisted  by  frictions  to  the  chest  of  the  mild  mercurial 
ointment,  or  by  the  method  of  Brodie,  which  is  to  smear  a  flannel 
jacket  with  the  ointment  and  wrap  it  around  the  thorax,  trusting 
to  the  natural  movements  of  the  child  for  its  friction  into  the  skin. 
In  some  instances  a  bath  is  mercurialized  by  dissolving  half  a 
drachm  of  the  bichloride  of  mercury  in  it,  and  employed  every 
two  or  three  days,  according  to  the  indications.  If  the  mercu- 
rial should  irritate  tlie  intestinal  canal,  its  administration  by  the 
mouth  is  suspended  for  a  while,  and  more  attention  paid  to  its 
use  by  the  bath.  In  addition  to  the  mercurial  treatment,  the 
iodide  of  potassium  is  administered  in  some  pleasant  syrup,  in 
doses  from  three-fourths  of  a  grain  and  upwards,  according 
to  the  age  and  strength  of  the  patient  and  the  promptness  of  its 
effects. 

Local  treatment  is  also  called  for.  The  mouth  may  be 
swabbed  out  with  honey  impregnated  with  muriatic  or  sulphuric 
acid,  or  with  alum  or  borax.  If  this  should  not  sufiice,  the 
diseased  parts  may  be  gently  touched  with  the  nitrate  of  silver, 
in  stick  or  in  solution,  great  care  being  taken  not  to  make  too 
extensive  an  application ;  and  this  may  be  repeated  every  two 
or  three  days,  according  to  the  indication. 

For  the  affections  of  the  nasal  passages,  the  syringe  should 
be   employed  several   times  a  day,  to  facilitate  the  removal 


122  SrPHILITIC    SORE   THROAT. 

of  the  cniBts,  and  to  medicate  the  diseased  structures.  Warm 
water  impregnated  with  the  bichloride  of  mercury,  chlorinated 
soda,  chloride  of  lime,  or  carbolic  acid,  may  be  employed  for 
this  purpose.  Ointments  containing  the  mercurial  may  also  be 
applied  by  means  of  a  soft  mop  or  feather, 


SOEE   THEOAT    FROM   BURNS    AND    SCALDS.  123 


CHAPTER    VIL 

SOEE    THEOAT   FEOM    BUENS    AND    SCALDS. 

BuENS  and  scalds  of  the  throat  are  often  met  with,  usually 
the  result  of  accident,  but  sometimes  the  result  of  design. 
They  are  often  fatal.  The  most  frequent  sufferers  from  scalds 
are  the  children  of  the  poor,  who,  being  allowed  to  run  al)Out 
the  kitchen,  attempt  to  drink  water  boiling  in  the  tea-pot. 
Sometimes  acid  or  alkaline  caustic  substances  are  swallowed,  a 
liniment  being  mistaken  for  a  mixture.  Another  class  of  cases 
occur  when  caustic  substances  are  swallowed  in  suicidal  intent. 
Burns  occur  most  frequently  from  the  inhalation  of  flame,  hot 
steam,  or  the  heated  air  of  burning  buildings.  "Where  flame 
or  hot  air  is  inhaled,  or  where  hot  or  caustic  liquid  is  swal- 
lowed involuntarily,  the  larynx  is  much  more  likely  to  be. 
implicated  than  when  the  drink  has  been  taken  designedly,  and 
the  epiglottis  not  surprised  at  its  post,  as  it  were;  and  the 
effects  are  produced  principally  in  the  pharynx  and  oesophagus. 
Wlien  the  larynx  has  been  injured,  acute  laryngitis  rapidly 
supervenes,  and  is  likely  to  be  attended  with  cedema,  and  thus 
produce  death  by  asphyxia.  Tracheotomy  is  therefore  demand- 
ed early,  as  a  rule,  after  accidents  of  this  sort ;  but  it  does  not 
hold  out  the  hope  of  success  in  children  that  it  does  in  adults. 

There  is  usually  little  trouble  about  the  diagnosis  of  a  burn  or 
scald  in  the  throat.  The  severe  pain  and  distress  in  the  part, 
the  dyspncea  and  dysphagia,  and  the  history  of  the  case  are 
suflficient  for  the  purpose.  The  mouth,  palate,  and  pharynx,  if 
seen  early,  are  white ;  patches  of  the  mucous  membrane  are 
destroyed,  and  there  is  abundant  evidence  of  inflammatory 
swelling.  The  nervous  shock  is  usually  very  great,  and  forms 
one  serious  element  of  danger. 

The  treatment  consists  in  the  administration  of  anodynes 
hypodermically  and  by  inhalation,  nourishment  and   stimula- 


124  SORE   THROAT    FROM    BURN'S    A]NrD    SCALDS. 

tion  by  enema,  and  the  local  application  of  bits  of  ice  in  the 
mouth,  with  cold  compresses  or  ice-bags  about  the  neck ;  to 
which  is  to  Ije  added  the  i)erformance  of  tracheotomy  on  the 
supervention  of  symptoms  of  suffocation.  Suppuration  is  very 
great,  should  the  patient  survive  ;  and  chronic  laryngitis  usually 
remains,  sometimes  with  stenosis  of  larynx  or  trachea,  and  stric- 
tm-e  of  cesophagus.  These  results  are  to  be  treated  according 
to  the  indications  laid  down  under  their  respective  heads. 

"When  smoke  is  inhaled  during  the  conflagration  of  burning 
buildings,  black  sputa  are  sometimes  expectorated  for  several 
days.  I  have  elsewhere  instanced'  a  number  of  cases  which 
occurred  in  a  family  living  over  a  perfumery  store  which  took 
fire.  Ten  of  them,  who  came  under  the  care  of  Dr.  W.  W. 
Keen,  Jr.,  and  myself,  were  attacked  ^vith  severe  bronchitis  and 
aphonia ;  and,  for  several  days  subsequent  to  the  accident,  ex- 
pectorated large  quantities  of  black  sputa,  which  were  nothing 
more  nor  less  than  the  carbonaceous  matters  they  were  forced  to 
inhale  before  they  could  be  rescued  from  the  flames.  In  one  of 
these  cases  there  was  oedema  of  the  larynx  thi-eatening  suffoca- 
tion. Copious  and  frequent  inhalations  of  the  spray  from  a 
solution  of  the  watery  extract  of  opium,  relieved  the  suffering, 
and  the  patient  eventually  recovered,^ 


^  Inhalation  ;  its  Therapeutics  and  Practice.     Phila.,  1867,  p.  294 
*  Ibid.  p.  139. 


SPECIAL    AFFECTIOIS^S    OF    THE    TONSILS.  125 


CHAPTEE    VIII. 

SPECIAL    AFFECTIONS    OF    THE    TONSILS. 

Foreign  Bodies,  such  as  fish-bones,  bristles  from  a  tooth- 
brush, and  the  hke,  occasionally  stick  in  the  tonsils.  Thev  may 
be  readily  remoyed  by  the  forceps.  If  deeply  buried,  an  incision 
may  be  made  oyer  them,  so  as  to  render  their  extraction  more  easy. 

Calcareous  concretions  are  sometimes  met  with  in  the 
tonsils.  They  yary  from  the  size  of  a  small  seed  to  that  of  a 
large  bean  or  a  small  nut.  They  often  produce  cough  and  ex- 
cessiye  secretion  ;  sometimes  inflammation  and  abscess.  Some- 
times they  project  from  the  surface  of  the  organ  and  can  be 
remoyed  by  the  forceps,  aided,  if  need  be,  by  one  or  two  light 
strokes  with  the  knife.  Small  concretions  are  occasionally 
ejected  spontaneously  in  a  fit  of  coughing  or  vomiting ;  and 
some  patients  are  subject  to  recurrences  of  this  kind.  These 
concretions  are  usually  composed  in  great  part  of  carbonate  and 
phosphate  of  lime,  and  seem  often  to  be  produced  from  calcifi- 
cation of  the  cheesy  masses  so  frequently  met  with  in  the 
tonsils.  Under  these  circumstances,  when  crushed,  they  emit 
the  same  offensiye  odor  as  the  masses  alluded  to.  Under  other 
circumstances  they  resemble  the  concretions  sometimes  expec- 
torated fi'om  the  lungs  of  tulDerculous  subjects,  and  haye  not  the 
slightest  offensiye  odor  about  them. 

Cancerous  tumors  occasionally  occur  in  the  tonsils.  Under 
these  circumstances  the  entire  organ  must  be  removed,  if  at 
all  subjected  to  operation ;  and  if  the  membranes  of  the  soft 
palate  or  pharynx  are  involved,  portions  of  these  structures 
also,  including  a  sufiicient  zone  of  healthy  tissue. 

Cystic  tumors  have  been  seen  in  the  tonsils.  They  have 
usually  been  discovered  during  an  operation  for  a  sujiposed 
hypertrophy.     The  contents  of  the  sac  are  of  com'se  evacuated 


126  SPECIAL    AFFECTIOI^S    OF   THE    TONSILS. 

by  the  operation  ;  and  an  injection  of  iodine,  or  some  analo- 
gous procedure,  should  be  employed  to  excite  adhesive  inflam- 
mations of  its  walls. 

PEEMAJS'EKT    (CHEOJSJIC)    EKLAEGEMENT    OF    THE    TONSILS. 

Hypertrophy  of  the  Tonsils. — Hypertrophy  of  the  tonsils 
is  very  often  met  with,  usually  in  children  and  young  adults. 
In  some  instances  the  affection  appears  to  be  congenital ;  at 
least  it  has  been  noticed  soon  after  birth.  It  is  very  rarely 
encomitered  in  persons  over  thirty  years  of  age,  unless  the  con- 
dition has  existed  for  a  number  of  years.  Most  of  the  cases 
occur  in  persons  of  the  strumous  diathesis,  and  often  in  connec- 
tion with  other  manifestations  of  this  condition  of  system, 
though  cases  are  sometimes  met  with  in  individuals  with  no 
other  evidence  of  scrofula. 

As  a  usual  thing,  there  is  a  history  of  successive  attacks  of 
sore  throat  during  which  the  tonsils  have  been  swollen,  each 
attack  leaving  them  larger  than  before ;  but  sometimes  there 
Is  no  history  of  this  kind,  and  we  are  led  to  the  conclusion 
that  the  affection  has  been  chronic  from  the  start.  A  mod- 
erate degree  of  hypertrophy  produces  no  unpleasant  symp- 
toms, except  while  the  patient  is  suffering  from  sore  throat, 
when  the  swollen  glands  interfere  with  deglutition,  and  some- 
times with  respiration. 

Great  hypertrophy  will  interfere  with  free  nasal  respiration, 
and  necessitate  more  or  less  coarse  breathing  through  the 
mouth,  and  thus  induce  dryness  of  the  throat.  It  also  produces 
a  peculiar  clang  in  the  voice,  and  gives  rise  to  snoring  during 
sleep. 

The  affection  is  recognized  at  a  glance  by  inspecting  the 
throat.  The  enlargement  may  vary  from  a  mei-e  projection  of 
the  glands  beyond  the  arches  of  the  palate,  to  an  hypertrophy 
so  great  as  to  hide  most  of  the  pharjmx,  the  tonsils  being  of  the 
size  of  large  walnuts,  and  touching  each  other.  In  some  in- 
stances they  have  been  known  to  become  adherent.  Mere  inspec- 
tion does  not  always  reveal  the  whole  of  the  enlargement,  and 
when  the  entire  cii'cumference  cannot  be  seen,  the  tinker  should 


CHP.OJSriC    HTPEETEOPHT    OF    THE    TONSILS.  127 

be  employed  in  examination,  when  the  gland  will  often  be  foimd 
enlarged  above  and  below,  in  the  former  instance  sometimes 
23ressing  the  palate  against  the  pharyngeal  orifice  of  the  Ens- 
tachian  tnbe,  and  thns,  perhaps,  adding  impairment  of  hearing 
to  the  nsual  symptoms  of  difficulty  in  deglutition,  respiration, 
and  articulation.  The  enlarged  tonsil  is  often  adherent  to  the 
arches  of  the  palate  to  a  greater  or  less  extent. 

The  enlargement  of  the  tonsil  is  not  due  to  a  growth  of  its 
glandular  structure,  but  rather  to  the  deposit  of  fibrinous  ma- 
terial within  its  structure,  which  material  undergoes  organiza- 
tion and  adds  to  the  size  of  the  organ. 

Both  glands  are  usually  hypertrophied,  but  not  always  to 
the  same  degree.  Sometimes  but  one  organ  is  affected,  and 
cases  of  this  kind  are  not  infi-equently  connected  with  incipient 
pulmonary  consumption,  as  pointed  out  by  Dr.  Green  and 
others,  the  affection  in  the  lung  showing  itself  on  the  same 
side  as  that  on  which  the  enlarged  tonsil  exists,  I  have  fre- 
quently  obser^-ed  an  enlarged  and  ulcerated  tonsil  in  cases  of 
tuberculosis,  and  almost  invariably  on  the  same  side  as  that  in 
which  disorganization  was  progressing  in  the  lung. 

The  ti'eatment  of  h}^3ertrophied  tonsils  is  both  constitutional 
and  local.  The  constitutional  treatment  consists  in  the  use  of 
nutritious  diet,  careful  attention  to  the  skin,  bowels,  and  kid- 
neys, and  the  use  of  cod-liver  oil  and  the  vegetable  tonics.  Iron 
also  is  often  indicated.  If  the  general  health  is  good,  remedies 
may  be  employed  with  a  view  to  promote  absorption,  such  being 
muriate  of  ammonia,  sulphate  of  potassa,  iodide  of  potassium, 
and  the  like.  Where  the  condition  is  of  comparatively  recent 
standing,  the  enlargement  moderate,  and  of  soft  or  elastic  con- 
sistence, constitutional  treatment  will  often  be  adequate  to  their 
reduction,  especially  in  cases  of  young  children.  In  addition  to 
constitutional  measures,  local  treatment  can  be  employed,  such 
as  the  use  two  or  three  times  a  week  of  solutions  of  nitrate  of 
silver,  tincture  of  iodine,  iodide  of  zinc,  glycerole  of  tannin, 
recent  ox-gall,  and  so  on ;  the  milder  remedies  being  applied 
night  and  morning  by  the  ]3arent  or  nurse. 

At  the  same  time  fi*equent  compression  of  the  gland  be- 
tween  the   fingers   of  each   hand— one   upon   the  tonsil,  and 


128  SPECIAL    AFFECTIONS    OF    THE    TONSILS. 

the  other  outside  of  the  throat — assists  the  process  of  absorp- 
tion. 

Where  the  tonsils  are  very  much  enlarged  and  very  hard, 
local  treatment  vs^ill  not  often  be  of  avail,  and  excision  must  be 
practised.  This  consists  in  the  removal  of  as  much  of  the 
tumor  as  projects  beyond  the  arch  of  the  palate.  Wlien  the 
organ  is  not  very  large,  it  may  be  excised  by  the  tonsillotome  of 
Physick,  Fahnestock,  or  others,  which  is  the  method  in  general 
use.  It  possesses  the  disadvantage  of  inability  to  practise  the 
excision  exactly  as  may  be  desired,  leaving  very  often  a  mis- 
shapen stump  behind. 

A  much  more  satisfactory  plan  consists  in  drawing  the 
enlarged  gland  out  from  its  bed  by  means  of  a  double  vulsel- 
lum,  and  cutting  it  with  a  large  probe-pointed  bistoury  from 
above  downwards  and  from  behind  forwards,  as  it  is  drawn 
obliquely  into  the  cavity  of  the  mouth.  The  danger  of  wound- 
ing the  carotid  artery,  which  is  often  referred  to  in  this 
connection,  does  not  exist,  inasmuch  as  the  organ  is  pulled  away 
from  the  side  of  the  throat,  and  other  structures  intervene 
between  this  vessel  and  the  tonsil.  It  can  only  occur  when  an 
awkward  attempt  is  made  to  excise  the  entire  gland,  a  sacri- 
fice which  is  hardly  ever  necessary.  It  is  sometimes  requisite 
to  remove  the  entire  gland,  in  cases  where  it  hangs  loosely  in 
the  throat  by  elongated  attachments,  and  danger  is  then  avoided 
by  keeping  the  knife  as  close  as  may  be  to  the  diseased  gland. 

When  the  patient  co-operates  wdth  the  surgeon  the  operation 
is  very  readily  accomplished,  but  when  struggling  occurs  it  is 
often  exceedingly  embarrassing,  from  the  difficulty  of  following 
the  course  of  the  knife  by  the  eye. 

On  account  of  the  difficulty  encountered  in  excising  an 
hypertrophied  tonsil,  especially  in  cases  of  refractory  children, 
a  special  instrument  for  this  purpose  was  invented  by  Dr.  Phy- 
sick and  Dr.  Fahnestock.  Fahnestock's  tonsillotome.  Fig.  29, 
has  had  a  more  extended  use,  perhaps,  than  any  other  special 
instrument  in  surgery.  It  consists  of  a  circular  knife  concealed 
within  a  ring  which  is  placed  over  the  enlarged  tonsil,  which  is 
then  transfixed  by  being  pierced  with  a  sharp  pointed  prong 
which   slides  on  the  shank  of  the  instrument.      The  handle 


CHRO]SriC    HYPEETROPHY    OF    THE   TONSILS. 


129 


attached  to  the  knife  is  then  drawn  home,  slicing  off  a  portion 
of  the  gland,  which  is  removed  with  the  instrument. 


Fi!?.  29. 


Fahnestock's  Tonsillotome. 

In  the  tonsillotome  of  Dr.  Phjsick,  Fig.  30,  a  broad-bevelled 
knife  is  pushed  forward  into  the  ring,  a  method  which 
prevents  dragging  the  tonsil  forward  by  its  attachments,  as 
sometimes  occurs  in  the  use  of  other  instruments.  It  can 
be  used  with  one  hand. 


Fig.  30. 


Physick's  Tonsillotome. 

An  instrument,  Fig.  31,  devised  in  France,  and  much  used  in 
this  country,  is  provided  with  a  mechanism  by  which  the  tonsil 
is  lifted  from  its  bed  to  the  desired  extent  before  the  knife  is 
drawn  home ;  the  entire  operation  being  performed  with  one 
hand,  and  in  one  movement,  the  fork  having  been  set  to 
the  desired  height  beforehand. 

Although  the  tonsil  is  richly  supplied  with  blood,  and  from 
several  vessels  of  tolerable  size,  the  hemorrhage  following  ex- 
cision is  usually  inconsiderable,  and  soon  ceases  spontaneously,  or 
upon  the  application  of  ice,  or  of  a  saline  or  acid  solution.  There 
are  several  records  of  more  than  a  thousand  operations  at  the 
hands  of  a  single  surgeon,  without  the  occurrence  of  any  serious 
hemorrhage.  On  the  other  hand,  there  is  no  doubt  that  hemor- 
rhage sometimes  takes  place  to  an  alarming  extent,  and  cases 

are  on  record  where  it  has  proved  fatal.     Hemorrhage  in  the 
9 


130 


SPECIAL    AFFECTIONS    OF    THE    TONSILS. 


Fig.  31. 


case  of  yoimg  cliildreii  is  a  very  serious  matter,  on  account  of 
the  difficulty  of  controlling  the  child  so  as  to  facilitate  efforts 
for  its  arrest.  I  have  seen  a  great  deal  of  hemorrhage  in  sev- 
eral cases,  and  in  one  in  particular,  a  young  married  lady  of 

about  twenty-five  years  of  age,  it 

was  alarming.      The  larger  tonsil 

had  been  excised  with  the  bistoury 

««  jw/     with  comparatively  little  bleeding, 

r     '  (mI^.L   so  little  thatthe  excision  of  the  other 

one  was  proceeded  with  immediate- 
ly.    As  I  cut  into  this,  the  hemor- 
rhage was  at  once  so  profuse  as  to 
conceal  the  field  of  operation  from 
view ;   but  the  excision  was  com- 
pleted as  rapidly  as  possible,  and  by 
the  time  the  divided  portion  of  the 
gland   was  withdrawn — less  time 
than  it  has  taken  to  narrate  the 
circumstance — several    ounces    of 
blood  had  been  lost.      I  immedi- 
ately applied  the  dry  persulphate 
of    iron,    slapping    it    upon     the 
bleeding  surface  with  my  fingers, 
which  held  it  there  with  some  diffi- 
culty on  account  of  the  struggles 
of  the  patient  to  eject  the  blood 
streaming  into  her  mouth.     Shortly 
after   the    hemorrhage    was    con- 
trolled, the  patient   fainted.      She 
was  placed  prone  on  the  floor  and 
soon  recovered.      Upon  examina- 
tion, a  few  minutes  after  the  ad- 
ministration    of     some     alcoholic 
stimulant,  I  found  that  I  had  not 
removed  the  lower  portion  of  the 
tumor,  having   cut   the   knife  out 
just  above  it.     With  some  persua- 
sion the  patient  permitted  me  to  remove  this  portion,  but  no 
bleeding  followed   it.     I  was  subsequently  informed  by  the 


Charriere's  TonsiUotome. 


CHRONIC    HYPERTROPHY    OF    THE    TONSILS.  131 

physician  who  had  brought  the  patient  to  me,  that  secondary 
hemorrhage  took  place  a  few  days  after,  which  necessitated  a 
renewal  of  the  application  of  the  persulphate  of  iron.  A  few 
weeks  afterwards  the  patient  called  upon  me  perfectly  well, 
but  she  had  not  yet  recovered  the  rosy  complexion  she  had  be- 
fore she  made  my  acquaintance. 

In  other  cases  I  have  found  the  operation  almost  a  bloodless 
one. 

On  account  of  the  danger  of  hemorrhage,  which  is  not 
at  all  avoided  in  the  use  of  the  tonsillotome,  it  has  been  pro- 
posed by  Chaissagnac  to  remove  the  gland  by  means  of  the 
ecraseur.  Some  surgeons  who  liave  attempted  this  have  found 
it  difficult  to  fix  the  gland  so  as  to  insure  the  division  of  suffi- 
cient of  its  substance,  and  the  drawing  of  nothing  else  within 
the  grasp  of  the  instrument. 

Prof.  Gross  has  recently  devised  an  instrument  for  this  pur- 
pose on  the  principle  of  the  tonsillotome,  substituting  a  chain 
for  the  knife ;  but  it  seems  suited  chiefly  for  cases  in  whicli  the 
hypertrophy  is  very  great. 

Maisonneuve  devised  an  instrument  for  removal  of  the  ton- 
sils, consisting  of  an  ecraseur  of  twisted  wire. 

Attempts  have  been  made,  and  Avith  success,  to  destroy  the 
exuberant  portion  of  the  tonsil  by  means  of  caustics.  Nitrate  of 
silver  is  inadequate  and  too  slow  in  its  action. .  The  Vienna  paste 
has  been  used,  but  it  is  very  painful,  and  cannot  be  kept  from 
other  tissues  except  by  means  of  a  special  contrivance  which  is 
not  always  at  hand.  Dr.  Morell  Mackenzie,  of  London,  has 
had  a  great  deal  of  success  with  the  use  of  the  London  paste, 
which  is  composed  of  equal  parts  of  caustic  soda  and  hydrated 
lime,  a  portion  of  which  is  moistened  with  water  at  the  time  of 
its  employment.  Dr.  Mackenzie  makes  the  application  with  a 
rod  of  aluminium  wire,  but  Dr.  Ruppaner,'  of  Kew  York,  has 
made  the  valuable  suggestion  of  using  a  glass  rod  for  the  pur- 
pose. I  have  employed  this  method,  and  sometimes  found 
it   available,  but  find  that  the  operation  needs  to  be  repeated 

'  On  the  Removal  of  Enlarged  Tonsils  without  Cutting.  With  123  cases. 
Med.  &8urg.  ifojj. ,  Phila. ,  1869,  Nov.  30,  37. 


132  CHEOlSnC    HTPEKTROPHY    OF    THE    TONSILS. 

many  times,  only  a  small  slougli  being  removed  after  each 
application.  It  has  the  merit  of  being  much  less  painful  than 
the  application  of  the  caustic  potash  or  the  Yienna  j)aste,  and 
of  being  followed  by  less  inflammation. 

Prof,  Donaldson,  of  Baltimore,  informed  me  quite  recently 
that  he  has  had  a  goad  deal  of  success  in  the  treatment  of  enlarged 
tonsils  by  making  small  incisions  into  them,  and  then  holding 
a  crystal  of  chromic  acid  in  the  cut  for  some  moments.  This 
method  he  prefers  to  that  recommended  hj  Dr.  Mackenzie. 

The  galvano-cautery  may  be  employed  for  the  purpose  of 
removal  by  a  single  operation,  the  tumor  being  first  encdrcled 
by  a  snare  of  platinum  wire,  which  is  drawn  as  tightly  as 
possible,  as  soon  as  the  electric  current  is  allowed  to  traverse  it. 

In  a  few  instances  of  soft  enlargements  of  moderate  dimen- 
sions, where  the  patients  refused  to  submit  to  operative  proce- 
dure, I  have  succeeded  in  reducing  the  glands  by  electrolysis, 
employing  a  long  platinum  or  gold  needle,  with  an  isolated 
handle,  in  connection  with  the  negative  pole  of  a  battery  of 
from  ten  to  forty  small  cells,  the  positive  pole  being  in  con- 
nection with  a  sponge-electrode  held  outside  over  the  tonsil, 
or  in  some  instances  upon  the  surface  of  the  gland  in  the 
mouth.  A  number  of  operations — ten  to  twenty — are  neces- 
sary for  the  accomplishment  of  this  purpose ;  and  in  some  of 
the  cases,  the  results  were  not  worth  the  trouble  of  the  perform- 
ance. 

I  must  say  that  I  prefer  excision  by  the  knife,  and  usually 
resort  to  it.  The  operation  is  facilitated,  in  certain  cases,  by 
first  detaching  the  gland  from  the  arches  of  the  palate  to  which 
it  has  contracted  adhesions.  These  bands  of  tissue  can  sometimes 
be  ruptured  with  the  probe,  or  some  similar  blunt  instrument. 
This  enables  the  gland  to  be  drawn  out  from  between  the  arch- 
es before  the  excision.  In  cases  of  moderate  enlargement  with 
adhesions,  the  simple  release  of  the  gland,  if  properly  maintain- 
ed, will  occasionally  assist  its  reduction  by  other  measures  with- 
out resort  to  the  knife. 


SPECIAL    AFFECTIONS    OF   PALATE    AND    UVULA.  133 


CHAPTEE    IX. 

SPECIAL    AFFECTIONS    OF    THE    PALATE    AND    UVULA. 

The  palate  participates  very  frequently  in  various  affections 
of  the  throat,  in  consequence  of  the  intimacy  of  its  connections 
with  pharynx,  tonsils,  nares,  larynx,  and  oesophag-us.  Recent 
researches  have  developed  some  new  points  in  connection  with 
the  musculature  of  the  soft  palate,  which  have  a  great  interest 
in  reference  to  the  physiology  of  deglutition,  and  occlusion  of 
the  upper  or  pharyngo-nasal  portion  of  the  pharynx,  and  con- 
sequently on  the  pathology  of  dysphagia. 

Inasmuch  as  these  observations  have  not  yet  been  generally 
introduced  into  our  works  on  anatomy,  a  brief  description  of 
their  special  points  will  hardly  be  out  of  place. 

THE   PHARYNGO-PALATINE    JVIUSCLES. 

Merke?  describes  both  of  the  pharyngo-palatine  muscles  as 
crossing  in  the  middle  line  of  the  posterior  wall  of  the  pharynx, 
and  then  each  of  them  coursing  further  on  the  opposite  side, 
to  unite  with  the  upper  fibres  of  the  inferior  constrictor  muscle 
of  the  pharynx ;  and  further  describes  them  as  taking  part  in 
the  function  of  the  constrictor  muscle.  A  sort  of  sphincter  is 
thus  formed,  which  can  shut  off  the  nasal  portion  of  the  pha- 
rynx ;  and  Merkel  considers  these  two  pharyngo-palatine  ■ 
muscles  as  forming  a  circular  muscle,  similar  to  that  of  the 
orbicularis  oris,  and  other  circular  muscles  of  the  body  which 
have  no  firm  points  of  insertion. 

Luschka'^  has  recently  studied  the  whole  subject  anew,  and, 
while  referring  to  the  author  just  named,  and  to  several  other 
authorities,  considers  the   pharyngo-palatine   muscles  of   each 

^  Anatomie  und  Physiologie  des  mensGhUchen  8Umm-  und  SpraeJiorganes. 
Leipzig,  1863,  pp.  317-224. 

*  Virchow's  ArcMv,  March  18,  1868,  p.  480-489,  with  illustrations. 


134         SPECIAL    AFFECTIOlSrS    OF    PALATE    AlfD    UVULA. 

side  to  form  a  whole,  which,  in  addition  to  the  function  of 
assisting  in  shutting  oif  the  naso-pharjng(^al  portion  from  the 
lower  portion  of  the  pharynx,  also  possesses  the  function  of 
shortening  the  pharynx,  and  raising  the  larynx  in  a  considerable 
degree.  Luschka  recognizes  a  thyroidal  portion  and  a  phai-yngo- 
palatinal  portion  of  the  muscle  under  consideration,  and  desig- 
nates it  as  the  musculus  thyreo-pharyngo-palatinus. 

The  main  points  of  Luschka's  description  may  be  thus 
summed  up : 

The  Thyreo-palatine  portion  of  the  Thy reo-pharyr  go- 
palatine  Musele.^ — The  upper  end  of  the  thyreo-palatine  por- 
tion of  the  muscle,  contained  in  the  soft  palate,  lies  partly  in 
front  of  the  levator  palati  and  partly  behind  it ;  its  fibres  in 
part  also  intertwining  with  the  substance  of  the  levator  itself, 
by  which  each  end  is  in  a  measure  separated  into  several 
strata.  Most  of  the  fibres  are  in  fi'ont  of  the  levator, 
forming  a  compact  arched  flattened  bundle,  whose  convex 
border  is  connected  firmly  with  the  aponeurosis  of  the  hard 
palate,  a  continuation,  as  it  were,  with  that  of  both  of 
the  tensores  veli,  while  its  concave  border  is  attached  to  the 
arch  of  the  levator  palati.  The  fibres  lying  behind  the 
levator  palati  muscle  form  several  bundles  of  different 
thickness,  loosely  connected,  which  become  more  and  more 
delicate  as  they  approach  the  fi^ee  border  of  the  velum,  and, 
without  forming  an  arch,  are  in  part  connected  with  the  apo- 
neuroses of  the  palate,  in  part  to  a  sort  of  median  raphe-like 
thin  prolongation  of  the  aponeurosis,  reaching  its  tendinous 
termination  behind  the  azygos  u^mlse.  The  combination  of 
fibres  enclosed  in  the  soft  palate  draw  themselves  together, 
downwards  and  outwards,  and  at  the  same  time  in  a  direction 
backwards,  more  and  more  into  a  roundish  flat  cord,  becoming 
gradually  thinner  towards  its  borders,  which  courses  down  in 
the  pharyngo-palatine  arch  behind  the  tonsil,  along  the  bend 
formed  by  the  posterior  and  lateral  walls  of  the  pharynx.  The 
bundle  which  takes  a  more  forward  position  at  the  base  of  the 
soft  palate,  courses  in  a  direction  more  and  more  horizontal  as  it 
descends,  and  flnally  comes  again  to  the  fi'ont.     These  muscular 


THE    PHAEHSTGO-PALATHSTE    MUSCLES.  135 

bundles  take  a  short  partial  attachment  on  the  posterior  border 
of  the  thyroid  cartilage,  below  its  upper  horn.  The  outer 
bundle  here  associates  itself  with  the  outer  portion  of  the  stylo- 
pharyngeus  muscle,  which  is  inserted  principally  in  the  upper 
corner  of  the  thyroid  cartilage,  a  few  delicate  fibres  stretching 
out  beneath  the  mucous  membrane  of  the  recessus  pharyngo- 
laryngeus.  I^Tot  a  few  bundles  of  the  pars  thyreo-palatina 
neither  remain  trae  to  the  original  direction,  nor  attach  them- 
selves to  the  thyroid  cartilage,  but  course  medianwards  to 
the  posterior  wall  of  the  pharynx,  where  they  form  a  long 
layer  of  fibres,  directly  under  the  mucous  membrane,  in  con- 
nection with  the  bundles  of  the  pharpigo-palatine  portion  of  the 
musculature,  which  layers  become  thinner  and  thinner  as  they 
reach  the  middle  line,  and  end  in  a  sort  of  aponeurosis  which 
loses  itself  in  the  oesophagus  as  a  lax  layer  of  coimective  tissue. 

The  Pharyngo-palatine  portion  of  the  Thyreo-Palatine 
Muscle. —  Close  by  the  arched  portion  of  the  pars  thyreo-palatina, 
this  portioii  of  the  muscular  apparatus  commences  in  a  flat  bundle, 
at  first  diagonally  placed  and  gradually  taking  a  direction  for- 
wards ;  arising  partly  from  the  aponeurosis  of  the  circumflex 
palati  mollis,  and  partly  from  fibrous  tissue  which  encloses  the 
convex  circumference  of  the  hamular  process  of  the  pterygoid 
plate,  so  that  it  is  connected  with  adjacent  immovable  points 
of  origin.  It  is  strengthened  by  the  salpingo-pharyngeus  muscle 
arising  from  the  cartilaginous  portion  of  the  Eustachian  tube. 

During  its  course  downwards  and  inwards  it  shows  itself  so 
behind  the  thyreo-jDalatine  portion,  coursing  outwards,  that  both 
portions  cross  each  other  at  a  very  sharp  angle  in  the  neighbor- 
hood of  the  lower  portion  of  the  tonsil.  The  fibres  then  course 
more  and  more  towards  the  middle  line  of  the  posterior  wall  of 
the  pharynx,  where  its  aponem*otic  expansion  not  only  becomes 
connected  with  the  fibres  from  the  thyi-eo-palatine  portion  at- 
tached to  the  thyroid  cartilage,  but  is  also  spread  out  between 
the  two  lower  horns  of  this  cartilage.  This  aponeurosis,  which 
can  be  readily  isolated  from  the  lower  constrictor,  is  gradually 
lost  in  a  lax  web  of  connective  tissue  which  passes  over  the 
submucous  tissue  of  the  oesophagus. 


136 


SPECIAL    AFFECTIONS    OF   PALATE   AND    UVfTLA. 


The  accompanying  cut  (Fig.  32),  copied  from  Luschka,  will 
give  an  idea  of  the  course  of  the  fibres  of  this  complex  muscle. 

Pig.  32. 


Anterior  -view  of  the  mnsculature  of  the  pharynx  and  palate  after  removal  of  tongue,  hyoid 
bone,  and  larynx,  as  far  as  the  posterior  segment  of  its  thyroid  cartilage.  From  Luschka  (Vir- 
chow's  ^rcAip,  March  18,  1868). 

A  Aponeurosis  of  the  soft  palate.  H  Pharyngeal  portion,  and 

B  The  thyroidal  portion  of  the  palato-pharj'n-  K  Palatal  portion  of  piilato-pharyngeus. 

gens.  L  Glosso-phiiryngeus. 

C  The  archlike  connection  of  the  levator  palati.   M  Hyo-pharyngeus. 
D  Azygos  uvulae  muscle.  N  Posterior  segment  of  thyroid  cartilage. 

F.  G.  Bundle  cf  constrictors  in  posterior  wall  of  I  Aponeurosis  of  thyreo-pharyngo-palatine  muf.- 
pharj'nx.  cle,  below  which  are  the  longitudinal  fibres 

of  the  ojsoplwgus  springing  from  it. 


TUMORS    OF   THE    PALATE.  137 


TUMOES    OF    THE   PALATE. 


Tumors  are  sometimes  formed  in  the  soft  palate.  They  may 
be  glandular,  cystic,  iibroid,  or  cancerous,  or  syphilitic.  In- 
spection and  palpation  determine  their  diagnosis.  They  are 
usually  removed  by  making  an  incision  into  the  mucous  mem- 
brane over  the  tumor,  and  then  peeling  the  growth  out  with 
the  fingers  without  the  use  of  the  knife.  An  operation  of  this 
kind  is  required,  as  the  tumors  may  enlarge  more  or  less 
rapidly,  and  give  rise  to  very  serious  symptoms,  necessitating 
a  very  severe  operation  on  account  of  the  extent  of  tissue  in- 
volved. Cystic  tumors,  with  fluid  contents,  are  emptied  by 
puncture  or  incision,  and  then  injected. 

The  following  translation,  fi'om  an  article  recently  published' 
on  adenomas  of  palate,  is  presented  on  account  of  its  interest, 
and  the  want  of  other  material  to  illustrate  this  subject : — 

"  In  1847,  ISTelaton,  operating  upon  a  patient  for  Kecamier, 
discovered  the  glandular  nature  of  a  tumor  of  the  soft  palate. 

"In  185T,  M.  L.  Rouyer  presented  to  the  Parisian  Society  of 
Surgery  a  resume  of  all  the  facts  then  known  concerning  these 
glandular  tumors  of  the  palate. 

"  Two  recent  observations  by  Dr.  Letenneur,  of  ISTantes,  give  a 
complete  picture  of  the  progress  and  symptoms  of  these  tumors, 
and  demonstrate  the  facility  with  which  they  can  be  enucleated. 

"  A  woman  of  robust  constitution  passed  through  an  attack  of 
typhoid  fever  in  1855.  During  convalescence  her  voice  was 
noticed  to  acquire  a  nasal  twang,  but  as  there  was  no  pain  or 
suffering  connected  with  it,  medical  advice  was  not  called  upon. 
It  was  not  until  Jan.,  1860,  that  the  alteration  in  the  timbre  of 
the  voice  increased  greatly,  when  it  soon  became  veiled  in  a 
A'ery  remarkable  manner.  At  this  period  a  physician,  in  con- 
versing with  the  woman,  was  struck  with  this  phenomenon, 
examined  her  mouth,  and  recognized  the  existence  of  a  large 
tumor.  The  voice  gradually  became  more  and  more  veiled  and 
nasal,  deglutition  began  to  become  difficult,  especially  for  liquids, 

^  Arch.  6 en.  de  Med..,  April,  May,  June,  1871,  p.  539.    From  Journ.  de  Med. 
deV  Quest,  30  Avril,  1870. 


138  SPECIAL    AFFECTIONS    OF    PALATE    AND    UVULA. 

and.  soon  even  solids  could  not  be  swallowed,  without  a  certain 
amount  of  annoyance.  On  May  2  the  patient  consulted  Dr. 
Letenneur,  and- he,  having  recognized  the  nature  of  her  affection, 
placed  her  in  the  hospital.  The  character  of  voice  resembled 
that  met  with  in  cases  of  enlarged  tonsils.  There  was  no  pain 
attending  the  difficulty  of  deglutition,  however.  On  looking 
into  the  mouth,  a  voluminous  tumor  was  found  upon  the  left 
side,  developed  froin  the  neighborhood  of  the  anterior  pillar 
of  the  j)alate,  the  mucous  membrane  of  which  enveloped  the 
growth  in  all  parts  accessible  to  the  view.  The  tumor  projected 
in  front  as  far  as  the  last  molar  tooth  but  one ;  it  pressed  the 
base  of  the  tongue  downwards  to  a  marked  degree,  and  pressed 
the  uvula  strongly  inwards  towards  the  right  side,  constricting 
the  isthmus  of  the  fauces  in  a  remarkable  manner,  so  that  the 
finger  could  not  be  insinuated  into  the  pharynx  without  some 
effort.  The  tumor  measured  six  centimetres  from  above  down- 
wards, and  about  four  and  a  half  centimetres  from  side  to  side. 

"Although  it  jjressed  the  wall  of  the  mouth  strongly  outwards, 
it  was  not  adherent  to  it,  but  could  be  circumscribed  on  all  sides 
except  below,  where  it  was  prolonged  towards  the  glosso-staphy- 
line  fold.  Above,  it  was  bounded  by  the  palate  bone,  and  was 
prominent  in  front  of  it.  Below,  it  did  not  project  in  an  ap- 
preciable manner  towards  the  pharynx,  and  was  not  confounded 
with  the  tonsil,  which  could  be  distinguished  by  the  finger.  Its 
exterior  aspect  did  not  differ  sensibly  from  that  presented  by 
the  rest  of  the  buccal  mucous  membrane,  except  that  some 
small  blue  veins,  moderately  developed,  coursed  on  its  surface. 
The  mucous  membrane  was  not  adherent  to  the  tumor.  To  the 
touch  it  appeared  bvit  little  hard,  without  nodulations,  offering 
to  pressure  a  doubtful  elasticity.  Carrying  the  finger  along  its 
surface,  some  fine  granulations  were  distinguished,  which  may 
be  compared  to  the  sensation  given  by  a  sac  of  thin  skin  filled 
with  millet-seed  softened  by  boiling. 

"An  operation  was  performed  May  10.  Assistants  depressed 
the  tongue,  and  kept  the  mouth  widely  open  by  means  of 
blunt  hooks.  An  incision  of  four  centimetres  was  made 
along  the  great  axis  of  the  tumor,  the  lips  of  the  wound  sepa- 
rated  of   themselves,    and    disclosed   a   whitish   woof,   which 


TUMORS    OF    THE    PALATE.  139 

formed  the  envelope  of  the  morbid  tissue.  After  having  cut 
awaj  some  slightly  resisting  adhesions,  the  two  index  fingers 
were  introduced  between  the  mucous  membrane  and  the  tumor, 
which  was  enucleated  without  any  difficulty.  The  tumor  broke 
into  fragments  under  the  digital  pressure,  but  was  completely 
removed.  The  debris  of  condensed  connective  tissue,  forming 
portion  of  the  envelope  or  cyst  in  which  the  tumor  was  con- 
tained, ^^ere  torn  aw^ay  with  the  fingers,  with  the  exception  of 
a  very  small  portion  which  descended  towards  the  base  of  the 
tongue,  and  which  -would  have  required  too  powerful  an  effort. 

"  The  loss  of  blood  was  insignificant,  and  the  walls  of  the  ex- 
tensive pouch  came  together  naturally.  The  tumor  weighed 
seventy-five  grammes. 

"  The  evening  of  the  operation  there  was  a  little  cephalalgia, 
and  some  pain  in  deglutition ;  but  on  the  following  day  every- 
thing was  in  good  order.  Cicatrization  took  place  rapidly,  and 
twelve  days  after  the  operation  the  patient  left  the  hospital 
completely  cured. 

"  Examination  of  the  Tumor. — The  fragments  were  of  the 
color  of  pale  rose  mingled  with  a  yellow  tinge.  On  crushing 
or  tearing  them,  fine  granulations  were  felt,  and  numerous 
tracts  were  seen  formed  by  the  vessels  and  by  a  woof  of  con- 
nective tissue.  Scraping  produced  no  juice.  A  microscopic 
examination  exhibited  the  glandular  nature  of  the  tumor.  The 
acini  were  concealed  by  a  very  abundant  embryonic  conjunc- 
tive tissue  forming  the  stroma.  Some  of'  the  acini  were  filled 
with  their  nuclear  epithelium,  and  in  each  preparation  it  was 
easy  to  find  free  epithelial  cellules.  There  was  no  evidence  of 
crystals." 

The  second  case  occurred  in  the  person  of  a  widow, 
set.  3S.  "  The  tumor  began  at  14  years  of  age,  following  the 
spontaneous  opening  of  a  gingival  abscess  which  ensued 
upon  extraction  of  a  sound  tooth  instead  of  the  diseased  one 
next  to  it.  Some  time  after,  she  discovered  near  the  region  oc- 
cupied by  the  abscess,  at  the  right  side  of  the  palate,  a  tumor 
the  size  of  the  end  of  the  finger,  which  gave  her  no  pain  on 
pressure.  In  Feb.,  1870,  a  physician  in  attendance  for  a  slight 
indisposition   remarked   the   palatine  tumor  while  examining 


140  SPECIAL    AFFECTIONS    OF    PALATE    AND    UVULA. 

the  tongue The    whole   right   side   of   the 

palatine  vault  was  covered  by  a  rounded  tumor,  which  seemed 
in  front  to  be  confounded  with  the  gums,  and  which  beliind 
passed  the  limit  of  the  osseous  vault.  The  median  raphe  was 
not  displaced,  and  the  veil  of  the  palate  was  perfectly  free.  The 
tumor  was  uniform,  and  some  dilated  veins  coursed  on  the  sur- 
face of  its  mucous  membrane,  which  was  somewhat  tense. 
With  the  finger  a  granular  mass  was  felt,  non-fluctuating,  non- 
elastic,  though  very  firm. 

"  The  operation  consisted  in  a  double  incision,  comprising  an 
elliptical  flap,  and  after  the  mucous  membrane  had  been 
dissected  to  the  right  and  to  the  left,  the  entire  morbid  mass 
was  extracted  by  the  finger,  the  enucleation  being  complete ;  but 
the  tumor  broke  into  several  portions.  There  was  considerable 
hemorrhage,  which  was  arrested  by  tamponing  with  dry  charpie, 
and  by  the  use  of  lotions  of  cold  water.  When  the  hemorrhage 
was  arrested  the  finger  was  placed  in  the  ca\aty,  and  it  was  found 
that  the  surrounding  parts  had  been  completely  isolated  from 
the  growth  by  the  condensed  connective  tissue  forming  the  walls 
of  the  cavity.  A  slight  hemorrhage  occurred  some  hours  after- 
wards, but  was  readily  arrested  without  recourse  to  the  tampon. 
There  was  fever  for  ten  days  following.  There  was  a  little 
swelling  of  the  edges  of  the  wound  for  about  a  week,  but  cica- 
trization took  place  satisfactorily  without  any  untoward  inci- 
dent. 

"  The  tumor  exhibited  the  same  characteristics  as  the  other 
one." 

Prof.  B.  Langenbeck '  has  reported  a  case  of  large  enchon- 
dromatous  tumor  on  the  under  surface  of  the  hard  palate,  which 
was  detached  from  the  mucous  membrane  and  bone  of  that 
structure.     Union  ensued  by  first  intention. 

Adhesions  of  the  palate  to  the  pharynx,  or  to  the  tongue, 
sometimes  occur  as  the  result  of  inflammation,  most  frequently 
in   connection  with  syphilis.     To   remedy  this   condition,   the 

1  {Deutsche  KUnik)  Canst.  Jahrb.,  Vol.  IV.,  1860,  p.  323. 


CLEFT   PALATE.      '  141 

parts  must  be  separated  with  the  knife,  and  the  edges  cauteriz- 
ed to  prevent  readhesion.  Bits  of  lint  may  be  interposed  to 
assist  this  purpose,  the  tents  being  attached  to  a  string  confined 
by  adhesive  strips  outside  of  the  mouth,  or  tied  around  the  ear ; 
vpithout  which  precaution  they  might,  when  detached,  fall 
into  the  larynx  or  upon  it,  and  produce  serious  consequences. 

An  instructive  case  of  extensive  adhesion  of  the  inferior  mar- 
gin of  the  soft  palate  to  the  posterior  wall  of  the  fauces,  with  a 
description  of  the  parts  seen  on  dissection,^  has  been  narrated 
by  Dr.  Wm.  Turner,  who  refers  to  two  similar  cases,  one  relat- 
ed by  Rudtorffer,"  and  the  other  by  Otto^ 

CLEFT    PALATE. 

This  affection  is  usually  congenital,  but  may  be  acquired  as 
the  result  of  disease  or  accident.  It  is  remedied  by  means  of  a 
surgical  operation,  or  by  the  employment  of  an  obturator  sup- 
plied by  a  skilful  dentist. 

In  operating  upon  a  case  where  the  cleft  concerns  the  soft 
palate  alone,  the  edges  are  pared,  silk  or  wire  sutures  are  insert- 
ed into  the  flaps,  and  the  parts  brought  together.  Undue  ten- 
sion is  relieved  by  division  of  the  levator  palati  muscles  on 
either  side,  and,  if  need  be,  by  division  of  the  posterior  palatine 
arch.  The  latter  operation  is  best  performed  below  the  tonsil ; 
and  the  former  by  the  method  of  Pollock,  which  is  to  insert  a 
double-edged  knife  through  the  anterior  mucous  membrane 
just  within  the  hamular  process,  and  then  to  divide  the  muscle, 
or  rather  saw  it  through,  by  raising  and  lowering  the  handle, 
producing  in  this  way  an  entire  division  of  the  muscle  without 
a  large  wound  anteriorly. 

Cleft  of  the  hard  and  soft  palate  may  often  be  permanently 
closed  at  one  operation.  Sometimes  the  parts  give  way  in  more 
or  less  of  their  extent,  necessitating  a  second  operation  for  the 
closure  of  the  gap. 

^  Edinh.  Med.  Jour.,  Jany.,  1860,  p.  612,  illustrated. 

"^  Abhandlung  uber  die  einfacTiste  und  sicTierste  OperationsmetJiode  eingesperr- 
ten  Leistern,  und  Sehenkelbrilche,  vol.  i.  p.  192.     Wien,  1805. 
^  Handhuch  der  Pathol.  Anat.,  p.  210,  note.     Breslau,  1813. 


142 


SPECIAL    AFFECTIONS    OF   PALATE  AND    UVULA. 


The  best  operation  is  that  of  Langeiibeck,  which,  with  a  slight 
modification,  the  author  has  completed  expeditiously  in  a  single 
operation  as  follows  :— 

The  mouth  being  distended  b}'  Elsberg's  modification  of  the 
gag  devised  b j  Smith  (figs.  33  and  34),  the  edges  of  the  entire  cleft 


Fig.  33. 


GeoT!EMANN  &iCo 

i      i 


Mouth  distender,  for  facilitating  the  operation  for  cleft  palate, 
and  other  operations  within  the  mouth. 

Fig.  34. 


Mouth  distender  in  position  for  the  operation  of  cleft  palate. 


were  split  instead  of  being  pared.  This  was  done  in  a  case  of 
enormous  cleft,  to  avoid  any  loss  of  tissue.  An  iiicision  was  then 
made,  according  to  the  indications  laid  down  by  Langenbeck,  on 


CLEFT    PALATE.  143 

each  side  of  the  alveolar  ridge  extending  from  a  line  on  a  level 
with  the  second  incisor  tooth,  as  far  back  as  the  last  molar,  the 
incision  penetrating  into  the  bone.  A  blnnt,  flat  blade  of  steel, 
bent  at  its  extremity  to  an  angle  of  about  forty-five  degrees,  was 
insinuated  beneath  the  periosteum,  and  gently  urged  forward 
with  a  sawing  motion  until  it  appeared  in  the  slit  at  the  cleft, 
the  instrument  being  kept  all  the  time  in  close  contact  with 
bone,  so  as  to  raise  periosteum  and  nmcous  membrane  together. 
This  motion  was  then  continued  upwards  and  downwards  until 
the  entire  flap  was  raised  free  from  the  bone.  The  elevator 
muscles  of  the  palate  were  then  divided  by  the  method  of  Pol- 
lock, tlie  incision  for  this  purpose  being  on  a  line  with,  and  close 
to,  the  posterior  portion  of  the  incision  through  the  hard  struc- 
tures. The  parts,  in  the  instance  referred  to,  came  together  with- 
out an}'^  necessity  for  section  of  the  posterior  palatine  arch,  which 
was  therefore  not  divided.  Wire  sutures  were  passed  through 
the  edges  of  the  flap  by  Langenbeck's  needle,  except  as  the  uvula 
was  approached,  when  a  needle  in  the  form  of  a  semicircle,  and 
held  in  Schwerdt's  forceps,  was  found  to  suit  better  for  these 
very  movable  parts.  Five  or  six  sutures  were  placed  in  the, 
hard  and  soft  palate,  and  two  in  the  uvula.  The  former  were 
secured  by  a  shot  on  each  side  of  the  cleft,  the  latter  by  a  single 
shot.  The  central  suture  cut  its  way  out  in  four  or  five  days  ; 
the  others  all  held,  and  in  eight  days  the  entire  wound  united, 
except  a  small  oval  opening,  comprising  the  place  which  had 
been  secured  by  the  suture  which  cut  out.  This  opening  gradu- 
ally contracted  to  the  size  of  a  small  pin-head. 

The  subject  of  cleft  palate,  though  belonging  to  the  surgery 
of  the  mouth  rather  than  that  of  the  throat,  is  mentioned  here, 
merely  to  draw  attention  to  the  success  attained  in  splitting  the 
edges  of  the  flap  instead  of  paring  them,  the  operation  being 
believed  to  be  unique  in  that  particular.  A  detailed  account 
of  the  operation,  and  the  circumstances  leading  to  it,  will  be 
published  elsewhere.  The  case  is  depicted  in  connection  with 
the  subject  of  glandular  hypertrophy  of  the  vault  of  the 
pharynx. 

For  the  best  account  of  operations  of  this  kind  that  I  have 
seen  in  English,  the  reader  is  referred  to  the  admirable  essay  of 


144  SPECIAL    AFFECTIONS    OF    PALATE    AND    UVULA. 

Dr.  Wm.  R.  Whitehead/  of  Kew  York,  a  gentleman  well  skilled, 
perhaps  no  one  more  so,  in  delicate  manipulations  of  this  kind. 

PARALYSIS    OF    THE   PALATE. 

Paralysis  of  the  palate  occurs  not  infrequently  as  a  sequel  of 
diphtheria,  and  is  alluded  to  in  the  description  of  that  affec- 
tion. 

A  paralysis  of  the  palate,  resembling  the  diphtheritic  paralysis, 
occasionally  occurs  independently  of  any  connection  of  this  kind, 
but  usually  following  some  affection  of  the  throat.  Cases  of 
this  kind,  following  cold,  or  sore  throat,  have  been  recorded' 
by  Drs.  Broadbent,  Weber,  Silver,  Anstie,  and  Gull. 

A  case  of  this  kind  came  under  my  own  care  some  eighteen 
months  ago,  in  which  the  paralysis  appeared  subsequent  to  the 
termination  of  a  successful  treatment  of  a  chronic  nasal  catarrh. 
The  mucous  membrane  of  the  turbinated  bones  had  been  very 
much  thickened,  and  was  freely  removed  with  forceps ;  this, 
and  the  local  use  of  salt  water,  constituting  the  essential  treat- 
ment. Some  months  afterwards,  the  patient,  an  intelligent  gen- 
tleman, some  thirty-five  years  of  age,  came  to  me  to  see  what 
could  be  done  to  remedy  a  difiiculty  of  swallowing  that  had 
been  gradually  coming  on.  There  was  an  impossibility  to  swal- 
low liquids ;  nearly  every  drop  of  liquid  swallowed  returned  by 
the  nose,  and  none  of  it  passed  into  the  oesophagus.  The  patient 
could  not  swallow  soup  ;  could  not  quench  his  thirst.  There  was 
no  trouble  in  swallowing  solids.  Examination  revealed  a  paralysis 
of  the  elevator  muscles  of  the  palate.  Treatment  by  electricity 
was  adopted,  the  negative  electrode  from  an  induction  apparatus 
being  promenaded  over  the  muscular  structure  of  the  palate 
anteriorly  and  posteriorly,  the  positive  electrode  being  placed  at 
some  indifferent  portion  of  the  body.  A  rather  protracted  treat- 
ment gradually  restored  the  lost  powers  of  deglutition,  but  the 
patient's  public  duties  required  his  presence  at  home  from  time 

'  AccoTint  of  a  new  and  very  successful  Operation  for  the  worst  forms  of  Cleft 
of  the  Hard  Palate  ;  with  a  brief  analysis  of  55  cases  ;  illustrated.  Am.  Jour. 
Med.  Sd.,  Oct.  1868,  p.  383. 

'  Med.  Times  and  Gaz.,  March  4,  1871,  p.  263-3. 


CHRONIC    ELOJSTGATIOJSr    OF    THE    UVULA.  145 

to  time,  which  rendered  the  treatment  longer  in  duration  than 
if  it  could  have  been  employed  continuously. 

SPECIAL    AFFECTIONS    OF    THE    UVLLA. 

Chronic  Elongation  of  the  Uvula. — The  uvula  is  liable  to 
elongation  with  and  without  hypertrophy.  Sometimes  the  mu- 
cous membrane  alone  is  elongated,  but  occasionally  the  muscular 
tissue  also.  When  hypertrophied,  the  excess  of  size  is  mostly 
due  to  interstitial  deposit  beneath  the  mucons  membrane.  AVhen 
the  mucous  membrane  alone  is  involved,  the  elongation  has  the 
form  of  a  thin  strip  of  tissue  tapering  to  a  point.  The  contact 
of  the  uvula  with  the  tongue  produces  a  tickling  sensation,  with 
a  disposition  to  hem  so  as  to  get  rid  of  it.  Sometimes  the  uvula 
dips  down  behind  the  epiglottis,  exciting  frequent  congh,  and 
not  unfreqnently  hoarseness,  fi-om  the  congestion  produced  in 
the  larynx.  Sometimes  suffocating  paroxysms  are  induced  in 
this  way.  These  symptoms  are  most  frequent  on  lying  down, 
which  favors  the  mechanical  condition  giving  rise  to  them. 
Occasionally  the  elongation  is  so  great  that  half  an  inch  of  the 
organ  rests  upon  the  tongue ;  and  one  or  two  cases  have  been 
recorded  in  which  the  enlarged  uvula  could  be  brought  between 
the  incisor  teeth. 

The  indication  for  the  relief  of  this  condition  consists  in  the 
removal  of  the  exuberant  portion;  an  operation  readily  per- 
formed by  seizing  the  tip  of  the  organ  with  a  pair  of  delicate 
forceps,  drawing  it  forwards  into  the  mouth,  and  then  dividing 
it  above  the  forceps  by  the  knife  or  a  pair  of  curved  or  straight 
scissors.  A  pair  of  straight  scissors,  with  a  guard  on  one  of  the 
blades,  to  prevent  the  organ  from  slipping,  insures  a  level  excision. 
If  carelessly  performed,  the  stump  will  be  longer  on  one  side  than 
another.  An  u^mlatome,  similar  in  construction  to  Physic's  ton- 
sillotome,  but  with  scissor-blades,  and  with  a  pair  of  forceps 
attached  below,  to  seize  the  uvula  as  it  is  divided,  renders 
the  operation  very  easy  of  performance. 

In  some  instances,  where  the  uvula  is  very  broad,  a  piece  is 
removed  shaped  like  an  inverted  Y,  and  the  flaps  are  brought 
together  by  silken  or  wire  suture. 
10 


140  SPECIAL    AFFECTIONS    OF    THE    UVULA. 

The  bleeding  after  excision  of  the  uvula  is  usually  insignifi- 
cant, but  occasionally  it  is  quite  profuse.  Under  these  circum- 
stances it  may  be  controlled,  as  in  a  case  recorded  by  Lisfranc, 
by  compressing  the  stump  between  the  blades  of  a  ]3air  of  for- 
ceps. 

The  parts  heal  readily  in  a  few  days.  Sometimes  a  mem- 
branous exudation  appears  on  the  divided  surface,  but  this  is 
rarely  of  any  moment.  Swallowing  is  sometimes  difficult  for  a 
few  days,  and  may  necessitate  the  employment  of  liquid  or  semi- 
solid food.  No  after-treatment  is  required  as  a  rule,  but  it  is 
as  well  as  not  to  encourage  the  use  of  a  mild  gargle,  such  as  one 
of  borax,  alum,  or  chlorate  of  potassa. 

Where  the  elongation  is  moderate  and  of  recent  date,  retrac- 
tion can  sometimes  be  produced  by  mechanical  irritation,  cau- 
terization with  nitrate  of  silver,  or  the  use  of  an  astringent 
lozenge  or  powder.  A  piece  of  catechu,  frequently  placed  on 
the  base  of  th-e  tongue  and  allowed  to  dissolve  there,  will  some- 
times accomplish  the  purpose.  Capsicum  applied  to  the  uvula 
sometimes  answers  extremely  well. 

(Edema  of  the  Uvula. — Qi^dema  of  the  uvula  sometimes 
occurs  during  the  progress  of  acute  or  chronic  sore  throat,  and 
the  organ  may  acquire  the  size  of  a  large  bean  or  even  that  of 
a  plum,  and  will  produce  sj)asms  of  asphyxia.  The  same  con- 
dition may  occur  from  the  incautious  use  of  caustics.  An  acci- 
dent of  this  kind  occurred  under  my  own  hands  some  years 
ago.  I  had  cauterized  the  soft  palate  of  a  syphilitic  patient,  in 
the  morning,  with  a  moderately  strong  solution  of  the  acid  ni- 
trate of  mercury.  I  was  routed  up  at  night  with  the  informa- 
tion that  my  patient  was  much  worse,  and  apparently  choking 
to  death.  On  arriving  at  the  bedside  and  looking  into  the  mouth, 
the  uvula  was  seen  to  be  swollen  by  cedema  to  the  size  of  the  ter- 
minal phalanx  of  a  man's  thumb.  Passing  the  tongue-depres- 
sor beneath  it,  it  was  raised  up,  and  all  suffocative  symptoms  van- 
ished. Cutting  off  the  end  with  a  pair  of  ordinary  scissors,  vent 
was  given  to  the  effused  serum,  and  the  unpleasant  comj)lication 
was  overcome. 

The  treatment  of  the  oedematous  uvula  consists  in  giving  vent 


AFFECTIONS    OF   THE    UVULA.  147 

to  the  fluid  by  incision,  or  excision  of  its  end.  Sometimes  the 
oedema  is  attended  by  hemorrhage  beneath  the  mucous  tissue, 
under  which  circumstance  the  color  of  the  swollen  organ  will  be  a 
blackish  blue,  instead  of  the  whitish  pink  of  ordinary  oedema. 
Sometimes  a  constriction  divides  this  portion  from  the  upper 
part  of  the  uvula.  A  puncture  and  the  use  of  astringent  washes 
will  usually  suffice  for  the  treatment. 

Excrescences  on  the  Uvula. — Excrescences  on  the  uvula 
are  occasionally  seen  in  cases  of  syphilis.  I  have  seen  them  also 
in  cases  of  phthisis.  If  they  are  of  large  size  they  may  give 
rise  to  the  unpleasant  symptoms  mentioned  under  the  head  of 
elongation  of  the  uvula.  They  are  readily  snipped  off  with  the 
scissors,  after  which  the  cut  surface  may  be  cauterized  by  the 
nitrate  of  silver. 

Bifid  Uvula. — A  bifid  uvula  is  occasionally  met  with  as  a 
congenital  condition.  Sometimes  inflammation  affecting  the 
uvula  will  be  conflned  to  one-half  of  the  organ,  and  thus  gives 
rise  to  the  appearance  of  bifid  uvula  with  one  limb  longer  than 
the  other. 


148  SPECIAL    AFFECTIONS    OF    THE    PHAKYNX. 


CHAPTER    X. 

SPECIAL    AFFECTION'S    OF    THE    PHARYNX. 

The  subject  of  pharyngitis  has  been  mentioned  in  connec- 
tion with  the  subject  of  sore  throat.  It  rarely  exists  as  an 
independent  affection,  except  under  the  conditions  to  be  de- 
scribed in  the  section  following. 

ABSCESS    OF    THK    PHARYNX. 

Under  certain  circumstances  of  inflammation  of  the  pharynx, 
an  abscess  is  formed  beneath  the  mucous  membrane,  which,  if 
not  recognized  and  properly  treated,  is  almost  certain  to  prove 
fatal  within  a  comparatively  short  period ;  usually  fi'om  pres- 
sure upon  the  upper  air-passages,  preventing  respiration,  but 
occasionally  from  starvation  also,  on  account  of  the  inability  to 
swallow.^  These  abscesses  sometimes  open  spontaneously,  but 
rarely,  inasmuch  as  death  is  likely  to  take  place  from  asphyxia 
before  the  matter  has  had  time  to  make  its  way  through  to  the 
surface. 

These  abscesses,  most  generally  known  under  the  name  of 
retro-pharyngeal  abscesses,  occur  at  all  ages,  but  a  large  majority 
of  the  cases  reported  have  been  encountered  in  young  children 
before  the  age  of  puberty,  frequently  during  the  first  few  months 
or  weeks  of  life  ;  and  they  have  been  observed  in  the  new-born 
babe.' 

The  anatomical  arrangement  of  the  parts  involved,  specially 
favors  the  formation  of  abscesses  in  this  region.  The  posterior 
wall  of  the  pharynx  is  attached  to  the  soft  parts  covering  the 
bodies  of  the  vertebrae  by  very  lax  and  ductile  connective  tis- 
sue, which  permits  a  great  deal  of  mobility  to  the  pharynx. 
Ample  room  is  thus  afforded  for  the  accumulation  of  purulent 

1  Carmichael;  Medico- CMrurgioal  Remeio,  Vol.  ii.  1821,  p.  518. 

2  Stromeyer's  HandbueJi  der  Chirurgie. 


ABSCESS    OF    THE    PHARYNX.  149 

matter,  which  usually  pushes  the  posterior  wall  of  the  pharynx 
forward  over  the  orifice  of  the  larynx ;  though  occasionally  the 
fluids  gravitate  towards  the  posterior  mediastinum,  and  are  then 
liable  to  perforate  the  oesophagus,  the  trachea,  or  the  pleural  sac. 

The  exciting  cause  of  this  aftection,  when  not  traumatic,  is 
usually  exposure  to  cold,  or  a  sudden  change  from  extreme  cold 
to  undue  warmth. 

Most  of  the  cases  occur  in  individuals  laboring  under  the  sy- 
philitic or  the  strumous  diathesis ;  and  these  cases  are  usually 
preceded  b}^  caries  of  the  cervical  vertebrae,  or  by  inflammation  of 
the  lymphatic  glands  which  exist  behind  the  posterior  wall  of  the 
pharynx.  Sometimes,  however,  they  follow  an  insidious  form 
of  inflammation  occupying  the  connective  tissue  between  the 
pharynx  and  the  vertebrae.  In  some  few  instances  the  disease 
seems  to  be  idiopathic.^  At  least  no  assignable  cause,  local  or 
constitutional,  can  be  detected  by  which  to  account  for  the  ap- 
pearance of  the  affection.  It  sometimes  follows  acute  inflam- 
mation of  the  tonsils  ;  sometimes  acute  inflammation  of  the  pha- 
rynx without  involvement  of  the  tonsils.  Occasionally  it  seems 
to  be  a  metastasis  of  erysipelas,^  several  cases  of  this  kind  being 
on  record.  As  traumatic  causes,  we  have  recorded  a  blow  of  a 
fencing-foil,  which  entered  through  the  nostril ; '  numerous  cases 
of  foreign  bodies,  princij^ally  pieces  of  bone  accidentally  swal- 
lowed,^ eight  cases  of  which  have  been  collected  by  Dr.  AUin;* 
the  swallowing  of  pins,*  etc. 

The  greatest  number  of  cases  of  retro-pharyngeal  abscess  occur 
in  connection  with  caries  of  the  cervical  vertebras,  and  there 


'  Gautier ;  Des  ahsees  retro-pharyngiens  idiopathiques,  021  de  Vangine  pMegmo- 
neuse.     Geneve  et  Bale.     1869. 

-Priou;  Am.  Jour.  Med.  Sci.^  Nov.  1830,  p.  251.  From  Hevue  Mediccde^ 
April,  1830.  Christopher  Flemmuig;  Dub.  Med.  Jour.,  vol.  xvii.  1840,  p.  58. 
Froriep's  Not.  xiv.  1840,  p.  157.   Mondiere;  Annales  d' Obstetrique,  Dec.  1842.  (?) 

=  Chas.  M.  AlUn;  N.  Y.  Jour.  Med.,  Nov.,  1851,  p.  329,  from  Morel,  Pam. 
Chir.  Journ.,  ii.,  1794,  p.  318. 

*  Cooper's  Lectures,  Phila.  ed.,  1839,  p.  68. 

^Retro-pharyngeal  Abscess.  N.  Y.  Jour.  Med.,  N07.  1851,  p.  307  et  seq. 
(58  cases.) 

°  PoUock  ;  in  Holmes'  System  of  Surgery,  Vol,  iv.,  p.  484. 


150  SPECIAL    AFFECTIOJSrS    OF   THE    PHAEYNX. 

often  coexist  symptoms  of  scrofulous  degeneration  or  syphi- 
litic contamination  elsewhere.  In  some  instances  the  caries 
of  the  vertebrae  is  preceded  by  inflammation  of  the  jjharynx. 
The  articular  surfaces  of  the  vertebrae  are  liable  to  be  the  seat 
of  the  disease,  and  in  this  way  dislocation  of  the  vertebrae 
occurs,  producing  pressure  upon  the  cord.  Nearly  all  cases  of 
abscess  of  the  pharynx  in  connection  with  caries  of  the  verte- 
brae prove  fatal,  even  when  the  abscess  has  been  properly  treat- 
ed, and  the  case  has  been  judiciously  managed  afterwards.  This 
is  particularly  the  case  when  the  abscess  is  at  all  large.  Prof* 
Stromeyer,  in  his  Manual  of  Surgery,  distinctly  states  that  he 
has  seen  all  of  his  cases  die  in  whom  caries  of  the  vertebrae 
had  given  rise  to  a  large  retro-pharyngeal  abscess.  Cases  are 
not  wanting,  however,  in  which  a  recovery  has  been  eifected, 
though  in  most  instances  attended  with  a  permanent  deformity 
from  the  altered  position  of  the  cervical  portion  of  -  the  spinal 
column.'  In  Dr.  Allin's  table  but  three  cases,  including  that 
of  Dr.  Flemming,  with  caries  of  the  vertebrae  are  recorded  as 
having  recovered,  and  in  these  the  terms  "  probable  "  and  "  sup- 
posed "  are  prefixed,  so  that  there  is  an  uncertainty  in  this  re- 
spect. 

Dr.  Syme^  has,  however,  narrated  a  case,  occurring  in  an 
adult,  in  which  a  large  portion  of  the  second  cervical  vertebra 
exfoliated  and  was  discharged  into  the  pharynx,  whence  it 
was  finally  removed  by  the  patient,  who  subsequently  recovered. 

Glinther'  narrates  a  case  of  Uhde's  (Deutsche  Klinik,  1856, 
p.  34),  in  which  the  bodies  of  the  third  and  fourth  cer- 
vical vertebrae  were  removed,  and  the  patient  recovered.  But 
as  this  occurred  in  a  case  of  syphilis  in  an  individual  forty  years 
of  age,  it  is  probable  that  the  usual  course  of  acute  abscess  was 
somewhat  modified. 

These  cases  are  altogether  exceptional. 

In  retro-pharyngeal  abscess  from  other  causes,  the  prog- 
nosis is  favorable  if  the  disease  is  early  recognized  and  prop- 


Ckristopher  Flemming,  Dublin  Quar.  Jour.  Med.  Sci.,  Feb.,  1850,  p.  234. 
Edinburgh  Med.  and  Surg.  Journ..,  Apl. ,  1826,  p.  311,  with  illustration. 
Lehrevon  den BluUgen  Operationen^  vol.  v.,  p.  7. 


ABSCESS    OF    THE    PHARYI^X.  151 

erly  treated.  If  undetected,  and  therefore  not  attended  to, 
death  from  asphyxia  will  in  all  probability  result  before  the 
abscess  has  matured  sufKciently  to  rupture  spontaneously. 
Many  an  instance  is  on  record,  even  at  comparatively  I'ecent 
dates,  in  which  the  disease  was  not  recognized  until  an  exami- 
nation post  moi'tem  ',  and  others  are  recorded  in  which  the 
existence  of  the  disease  was  likewise  unsuspected,  and  the 
patient's  life  saved  only  by  the  fortunate  rupture  of  the 
abscess,  explaining  the  nature  of  the  difhculty.  Dr.  Allin  re- 
cords in  his  tables  a  case  which  occurred  in  the  New  York 
Hospital,  August,  1849,  in  which  the  patient  was  being  treated 
for  syphilitic  ulceration  of  the  throat,  and  the  abscess  was  acci- 
dentally ruptured  during  the  introduction  of  a  probang^ 
employed  for  the  purpose  of  applying  a  solution  of  nitrate  of 
silver  to  the  parts,  the  true  nature  of  the  disease  having  been 
neither  recognized  nor  suspected.  This  fortuitous  accident 
probably  saved  the  life  of  that  patient. 

Those  cases  due  to  the  presence  of  a  foreign  body,  it  is  per- 
haps impossible  to  cure  by  removal  of  the  offending  substance, 
inasmuch  as  it  must  be  completely  hidden  by  the  swelling. 
The  abscess  must  be  treated,  therefore,  in  just  the  same  man- 
ner as  abscesses  from  other  causes.  Sometimes  the  foreign 
body  remains  embedded  in  the  soft  parts  covering  the  vertebrae 
to  which  it  has  penetrated.  Sometimes  it  is  loose  in  the  fluids 
of  the  abscess.  These  points  have  been  verified  hj post-mortem 
examinations.  In  some  instances  the  foreign  body  has  been 
discharged  with  the  contents  of  the  abscess.  More  fi^equently 
the  foreign  body,  usually  a  piece  of  bone,  passes  onward  into 
the  stomach  after  having  produced  the  injury.  In  one  of  the 
cases  collected  by  Dr.  Allin'  the  bone  passed  through  the 
alimentary  tract  and  escaped  per  anum ;  though  not  extracted 
thence  without  a  good  deal  of  pain. 

Two  cases  are  recorded  by  Mr.  John  Adams,^  in  one  of  which 
the  impaction  of  a  fish-bone  into  the  vertebral  column  resulted 
in  caries,  followed  by  abscess. 

'  M.  Fillean.,  quoted  by  Gibert.     London  Lancet,  June,  1828,  p.  393,  from 
Arch.  Oen.  de  Mid. ,  May,  1828. 
"^  London  Lancet,  June,  1847,  p.  581. 


152  SPECIAL    AFFECTIONS    OF    THE    PHARYNX. 

Retro-pharjngeal  abscess  has  occasion  allj^  perforated  tlie  in- 
ternal carotid  artery,  by  extension  behind  the  tonsil,  producing 
death  by  hemorrhage ;  cases  of  which  have  been  reported 
by  Holzle,'  Leishman,^  and  others. 

In  view,  therefore,  of  the  importance  of  this  malady  as 
regards  the  direct  responsibility  of  the  medical  attendant 
in  reference  to  a  fatal  issue,  it  is  incumbent  on  the  practitioner 
to  bear  its  likelihood  in  mind  in  all  cases  of  disease  of  the 
throat  impeding  respiration  or  obstructing  deglutition,  in  order 
that  a  due  ocular  inspection  and  digital  exploration  of  the 
parts  should  be  instituted  ;  simple  measures  which  promptly 
decide  the  diagnosis.  In  some  instances  the  patient  cannot 
open  the  mouth  wide  enough  to  permit  an  inspection  of 
the  parts,  and  then  we  have  to  depend  upon  the  touch  alone. 
In  most  instances,  however,  the  mouth  can  be  opened  far 
enough  to  permit  a  good  view  of  the  pharynx  by  depressing 
the  tongue  with  a  tongue-depressor,  the  handle  of  a  sp'oon,  or  a 
lead-pencil.  On  looking  into  the  pharynx,  we  observe  that  its 
posterior  wall  projects  into  the  cavity  of  the  organ  in  some 
portion  of  its  extent,  forming  a  tumid  swelling  which  en- 
croaches on  the  calibre  of  the  tube.  When  this  is  high  up,  the 
soft  palate  lies  upon  it ;  but  sometimes  the  entire  abscess  is  at  a 
lower  level.  There  are  usually  other  evidences,  than  the  mere 
swelling,  of  inflammation  of  the  mucous  membrane  of  the 
pharynx  and  adjacent  parts,  over  which  congested  blood- 
vessels are  seen  to  course,  and  on  which,  occasionally,  spots  of 
ecchymosis  are  irregularly  distributed ;  but  in  a  great  many 
cases  there  is  no  evidence  whatever  of  inflammation  beyond 
that  of  the  swelling  itself. 

Palpation  with  the  flnger  reveals  the  fluctuating  character 
of  the  swelling,  and  stamps  the  diagnosis  of  abscess ;  for  a  simi- 
lar appearance  of  the  parts  may  exist  in  cases  of  tumor  of  the 
pharynx,  and  mere  inspection,  therefore,  may  be  deceptive. 

The  general  symptoms  of  the  affection  which  point  to  the 
probable  existence  of  an  abscess  are :  pain  and  soreness  in  the 


SchmidVs  JaJirb. ,  98,  xcviii. ,  p.  312. 

GlasgoiD  Med.  Journ.,  N.  S.,  May,  1869,  p.  405. 


ABSCESS    OF    THE    PHAEYJSTX,  153 

parts,  referred  to  the  palate  when  the  abscess  reaches  high  up, 
but  often  extending  over  the  entire  throat ;  difficulty  of  swal- 
lowing, amounting  in  some  instances  to  complete  dysphagia ; 
some  impediment  to  respiration,  the  dyspnoea  often  increasing 
to  such  an  extent  as  to  compel  the  maintenance  of  the  semi- 
erect  posture.  The  voice  is  sonorous,  but  produced  with  difficulty, 
and  is  muffled  or  nasal  in  tone.  External  pressure  and  movement 
of  the  stiff  neck  will  produce  pain,  or  reveal  tenderness.  There  is 
usually  some  distinct  history  of  an  attack  of  chilliness  or  shiver- 
ing, deuotive  of  the  formation  of  pus.  All  the  usual  plienomena 
of  obstructed  respiration  occur,  and  there  are  the  ordinary  symp- 
toms of  suppurative  inflammation,  such  as  acceleration  of  the 
pulse,  heat  of  skin,  and  actual  increase  of  temperature.  Asso- 
ciated with  these  symptoms,  there  are  in  many  cases  external 
manifestations  of  tumefaction  about  the  throat,  sometimes  at  one 
point,  sometimes  at  two  or  three,  increasing  in  volume  as  the  dis- 
ease progresses.  The  principal  point  of  swelling  is  behind  the 
external  angle  of  the  jaw,  in  the  depression  in  front  of  the 
border  of  the  sterno-cleido-mastoid  muscle ;  and  upon  this  point 
Mondiere  lays  great  stress,  having  observed  it  in  all  his  cases  of - 
chronic  retro-pharjaigeal  abscess.  Sometimes  the  larynx  is 
pushed  forward  so  as  to  be  rendered  unusually  prominent.  In 
cases  in  which  the  matter  gravitates,  the  swelling  will  extend 
lower  down,  and  in  one  fatal  case'  has  been  described  as  simu- 
lating disease  of  the  thyroid  gland. 

Sometimes  the  abscess  is  formed  between  the  membranous 
wall  of  the  pharynx  and  the  sheaths  of  the  muscles,  in  which 
instances  there  will  be  but  little  interference  with  deglutition, 
and  the  cases  may  have  time  for  full  progression  so  as  to  rup- 
ture spontaneously. 

In  one  form  of  this  disease  the  abscess  forms  behind  both 
pharynx  and  oesophagus.  Mondiere^  has  reported  eleven  such 
instances  in  adults,  and  seven  in  children  varying  in  age  from  a 
few  weeks  to  four  years.  Most  of  these  cases  arose  from  caries 
of  the  vertebrae,  but  the  cause  of  the  affection  was  not  always 

'  J.  Henry  Clark,  iV.   7.  Jour.  Med.,  July,  1849,  p.  34. 
^  Giintlier  :  op.  cit. ,  p.  6. 


154  SPECIAL    AFFECTIONS    OF    THE    PHAEYNX. 

apparent.  Three  eases  followed  inflammation  of  the  throat ; 
one  case  appeared  to  have  been  a  metastasis  of  erysipelas  ;  two 
cases  were  of  rheumatic  origin  ;  and  one,  in  a  case  of  stricture 
of  the  cesophagus,  originated  apparently  from  overstraining  in 
attempts  to  swallow  large  morsels  of  food. 

It  has  been  mentioned  that  the  contents  of  the  pharyngeal 
abscess  sometimes  gi-avitates  behind  the  oesophagns,  bnt  there  are 
also  cases  in  which  the  abscess  commences  in  this  region,  forming 
a  variety  which  has  been  named  retro-oesophageal  abscess.  Like 
the  ordinary  form,  this  variety  is  also  due  principally  to  inflam- 
mation and  caries  of  the  vertebrae.  Glinther  describes,  after 
Duparcque,'  a  number  of  symptoms  which  serve  to  distinguish 
this  variety,  the  principal  of  which  are  the  following  : — 

The  swelling  in  the  lateral  region  of  the  neck  is  lower  down, 
occupies  a  position  further  forward,  and  especially  upon  the 
left  side.  The  food  swallowed,  instead  of  remaining  in  the 
mouth,  or  being  driven  through  the  nostrils,  is  carried  down- 
wards, some  of  it  being  swallowed,  but  some  of  it  passing  into 
the  larynx  and  producing  severe  paroxysms  of  cough.  The 
walls  of  the  entire  larynx  being  pressed  together,  the  voice  is 
shrill,  piping,  and  comparable  to  that  of  a  duck: 

The  relief  to  respiration  by  the  sitting  posture  is  not  as 
marked.  Pressure  upon  the  oesophagus  produces  more  pain 
than  pressure  upon  the  larynx  or  the  upper  portioii  of  the  tra- 
chea. Pressure  upon  the  larynx  prevents  respiration  entirely, 
and  produces  paroxysms  of  asphyxia.  The  abscess  is  not  felt 
through  the  mouth. 

These  cases  terminate  fatally.  Sometimes  they  rupture  into 
the  oesophagus.  Several  cases  are  mentioned  by  Giinther,  from 
the  records  of  Duparcque,  Noll,  and  Uhde. 

Treatment. — The  proper  treatment  for  these  abscesses  consists 
in  timely  opening  them  by  the  knife  to  give  free  egress  to  the 
pus.  For  this  purpose  the  best  method  is  to  place  one  forefinger 
upon  the  abscess,  and  then  to  j^ass  along  it  a  sharp  bistoury, 
protected  to  within  half  an  inch  of  its  point,  and  to  make  a  free 
opening  longitudinally.     Sometimes  it  maj'  be  better  to  make  a 

'  ScJimidVs  Jalirh.,^.  Supplement,  p.  191. 


ABSCESS    OF    THE    PHAEYIirX.  155 

transverse  incision.  Sir  Astley  Cooper,  Prion,  Flemming,  and 
others  employed  an  ordinary  or  specially  arranged  trocar  and 
canula.  In  one  instance  puncture  with  an  exploring-needle 
answered  the  purpose.  Dr.  AUin  objects  to  the  use  of  the 
trocar,  on  account  of  the  danger  of  piercing  the  vertebrae,  and 
thus  ffivinp;  trouble  afterwards,  AVhere  the  abscess  extends  be- 
hind  the  tonsil,  special  care  is  requisite  on  acconnt  of  the  prox- 
imity of  the  carotid  artery.  The  abscess  has  also  been  opened 
by  the  finger-nail,  and  in  some  instances  mere  pressure  with  the 
finger '  has  sufticed  to  rupture  the  walls  of  the  abscess. 

The  contents  of  the  abscess  are  nsnally  discharged  by  the 
mouth,  bnt  this  is  not  invariably  the  case.  Giinther "  mentions 
an  observation  of  Petrnnti,  in  which  the  pus  descended  along 
the  lateral  walls  of  the  throat,  pushing  the  larynx  forward,  and 
producing  such  difiiculty  in  breathing  that  an  external  incision 
became  necessary  in  order  to  save  the  life  of  the  patient.  In 
this  case  the  pns  was  found  between  the  pharynx  and  larynx. 

In  some  instances  there  is  such  relaxation  of  the  connective 
tissue  between  the  parts  involved  in  the  disease,  that,  after 
evacuation  of  the  abscess,  pus  accumulates  behind  the  pharynx, 
below  the  line  of  the  wound  made  by  the  incision.  In  these 
cases  Giinther  recommends  slitting  the  sac  longitudinally  and 
injecting  solutions  of  an  irritating  character. 

In  cases  of  retro-oesophageal  abscess,  the  necessity  for  per- 
forming tracheotomy  sometimes  becomes  imperative. 

Where  retro-pharyngeal  abscess  has  been  the  result  of  acute 
inflammation,  the  parts  usually  heal  rapidly  after  discharge  of 
their  contents,  much  in  the  manner  of  subsidence  in  abscess  of 
the  tonsil  after  incision.  Occasionally,  however,  a  large  ulcer 
will  remain  and  impede  deglutition  until  granulation  is  well 
established. 

A  few  remarks,  in  conclusion  of  this  subject,  are  requisite  in 
relation  to  the  differential  diagnosis.  As  the  affection  occurs 
most  frequently  in  children,  it  is  apt,  from  the  similarity  of  some 


'  Christoplier  Flemming  :  Dub.  Quart.  Jour.  Med.  >Sci.,Feb.,  1850,  p.  224. 
Froriep's  Not.  xiv. ,  p.  153. 
2  Op.  cit.,  p.  6. 


156  SPECIAL    AFFECTIOlSrS    OF    THE    PHAKYNX. 

of  the  symptoms,  to  be  confounded  with  croup.  In  the  adult 
it  may  be  mistaken  for  oedema  of  the  larynx. 

The  existence  of  an  abscess  of  this  kind  may  be  suspected  in 
a  child  when  attacked  by  frequent  suffocative  paroxysms,  simi- 
lar in  many  respects  to  those  encountered  in  croup,  but  not  ex- 
hibiting the  same  distinctness  of  remission.  The  restlessness  of 
the  patient  and  the  actual  obstruction  to  respiration  is  said  to  be 
greater  than  that  witnessed  in  croup  ;  and  the  relief  to  respira- 
tion afforded  by  the  sitting  posture  may  be  taken  as  another 
indication  of  the  nature  of  the  disease.  The  voice  is  not  affected 
as  it  is  sometimes  in  croup,  there  being  no  impediment  to  the 
free  vibration  of  the  vocal  cords.  Pressure  upon  the  parts 
always  produces  pain,  which  is  not  the  case  in  croup.  If  there 
be  any  external  swelling  in  croup,  it  will  be  below  the  angle  of 
the  jaw  ;  while  it  is  farther  forward  in  retro-pharyngeal  abscess, 
and  more  deeply  situated  beneath  the  sterno-cleido-mastoid 
muscle. 

CEdema  of  the  larynx  is  more  sudden  in  its  onset,  and  the 
obstruction  to  breathing  occurs  principally  in  inspiration,  from 
the  valve-like  action  of  the  fluctuating  folds  of  oedematous  tissue, 
as  more  fully  described  in  the  article  on  that  affection.  Digital 
exploration  and  ocular  inspection,  direct  or  in  the  laryngoscopic 
mirror,  will  set  all  doubts  at  rest. 

The  after-treatment  of  this  disease  will  depend  upon  the 
peculiarities  of  the  case,  and  the  nature  of  the  constitutional 
dyscrasia;  and  it  is  to  be  conducted  on  the  general  principles 
of  therapeutics. 

CHEONIG   FOLLICULAR   PHARYNGITIS. 

The  exact  manner  in  which  chronic  follicular  pharyngitis 
commences  is  not  well  known,  for  it  is  only  when  a  patient  has 
been  suffering  more  or  less  for  a  considerable  time,  that  he  be- 
comes conscious  of  the  existence  of  a  permanent  disease  of  the 
throat,  leading  him  to  solicit  the  assistance  of  a  medical  practi- 
tioner :  and  very  often  the  annoyance  endured,  though  constant, 
is  so  slight  in  character,  and  so  little  liable  to  aggravation,  that 
he  is  still  longer  deterred  from  seeking  professional  aid.  In 
this  manner  it  happens  that  the  physician  is  rarely  afforded  an 


CHRONIC    FOLLICULAR    PHARYNGITIS.  157 

opportunitj  of  seeing  the  disease  until  after  it  has  ah-eady  existed 
for  several  months  or  several  years.  The  story  of  the  patient,  with 
some  variations  and  modifications,  will  in  most  cases  run  thus  : 
— that  some  months  or  some  years  back,  there  gradually  forced 
itself  upon  the  consciousness,  a  sense  of  the  existence  of  perma- 
nent trouble  in  the  throat.  This  may  "have  been  mere  dryness, 
with  or  without  a  disposition  to  cough  or  to  expectorate  ;  but 
some  disposition  or  other  to  clear  the  throat  from  a  foreign 
body  is  almost  always  spoken  of  as  an  early  manifestation. 
With  this  there  may  be  connected,  and  certainly  will  be  sooner 
or  later,  if  the  disease  continues,  some  degree  of  hoarseness, 
inequality,  or  impairment  of  the  voice,  the  patient  being  unable 
to  depend  upon  it  for  public  purposes.  In  some  cases  more  or 
less  trouble  is  experienced  in  swallowing.  In  some  there  is 
more  or  less  impairment  of  hearing.  Pain  is  not  often  com- 
plained of  very  early  in  the  disorder,  and  the  discomfort  is 
usually  more  that  of  an  annoying  sensation,  referred  to  a  feeling 
as  of  the  presence  of  some  foreign  body,  as  a  hair,  a  bristle,  a  pin, 
a  lump,  and  so  on.  Sometimes  there  will  be  headache,  distinctly 
referable  to  exacerbation  of  the  throat  trouble.  Usually  there 
will  be  more  or  less  symptoms  of  dyspepsia  and  indigestion. 
Yery  often  coolness  of  the  extremities  will  be  complained  of. 
With  all  these  symptoms,  the  patient  will  feel  in  tolerable  good 
health,  and  be  still  able,  with  more  or  less  effort,  to  attend  to  his 
ordinary  avocations. 

When  the  history  of  the  disease  is  recounted  at  a  later  date, 
we  will  be  informed  of  the  above  enumerated  symptoms,  and 
be  then  told  that  they  gradually  increased  in  severity,  some- 
times with  constant  progression,  sometimes  as  a  result  of  expo- 
sure to  changes  of  temperature,  which  would  be  followed  by  an 
aggravation  of  symptoms,  subsiding  to  some  extent  in  a  few  days 
or  weeks,  and  the  result  remaining  stationary  until  the  occurrence 
of  a  fresh  accession.  The  trouble  with  the  voice  will  have  gradu- 
ally increased,  and  in  the  case  of  clergymen  and  other  public 
speakers,  have  perhaps  proceeded  so  far  as  to  disable  them  from 
performance  of  their  pastoral  or  secular  duties.  The  cough  will 
have  become  more  frequent,  accompanied  by  the  expectoration 
of  viscid  mucus,  and  attended  with  a  scratching  or  still  more 


158  SPECIAL    AFFECTIONS    OF    THE    PHARYNX. 

unpleasant  or  even  painful  sensation  in  the  throat,  usually 
referred  to  the  pharynx  at  the  region  of  the  base  of  the  tongue, 
or  to  the  larynx.  Respiration  is  affected  at  times,  but  that  diffi- 
culty is  of  nervous  origin  altogether.  Dysphagia,  too,  is  occa- 
sionally complained  of,  and  is  also  usually  nervous  in  character. 

As  a  rule,  the  patient 'will  have  tried  a  great  variety  of*  local 
and  systemic  rem^edies,  which  have  failed  in  aifording  relief ; 
and  much  of  the  intestinal  disturbance  that  is  complained  of 
may  be  due  to  the  effect  of  the  medicines  that  have  been 
employed. 

The  causes  of  this  affection  are  not  thoroughly  understood.  It 
makes  its  appearance  in  individuals  of  all  classes,  without  dis- 
tinction of  temperament,  'social  position,  or  employment.  It 
probably  never  occurs  as  a  direct  result  of  acute  inflammation 
of  the  pharynx,  though  it  is  easy  to  understand  how  repeated 
attacks  of  sore  throat  of  an  acute  or  subacute  character  would 
gradually  bring  about  the  condition  under  consideration.  Un- 
der such  circumstances  the  causes  would  be  those  already 
enumerated  under  the  head  of  sore  throat ;  and  the  less  effec- 
tive but  persistent  exposure  to  the  same  class  of  causes  could 
very  well  gradually  induce  a  condition  of  chronic  inflammation, 
without  there  havang  been  any  previous  acute  or  subacute  in- 
flammation. It  is  highly  probable  that  in  the  majority  of 
instances  the  cases  are  of  a  chronic  character  from  begiiming  to 
end. 

Although  this  affection,  from  its  prominence  among  the 
clergy,  has  received  the  appellation  "  clergyman's  sore  throat," 
it  is  by  no  means  confined  to  members  of  that  profession,  nor 
even  to  public  speakers.  Professor  Green,  our  great  authority 
on  this  disease,  writes :  "  Of  nearly  four  hundred  cases  that 
have  fallen  under  my  observation,  only  about  seventy-eight,  or 
one  in  five,  of  this  number,  were,  in  any  way,  public  speakers." 
But  it  is  evident,  as  he  adds,  that  "  when  the  affection  does 
occur  in  those  persons  who  are  in  the  habit  of  exercising  the 
vocal  organs  by  public  speaking,  singing,  teaching,  etc.,  it  is 
alwavs,  for  obvious  reasons,  attended  with  symptoms  of  a  more 
aggravated  nature  than  when  it  appears  under  ordinary  cir- 
cumstances." 


CHEONIC    FOLLICULAR    PHARYNGITIS.  loP 

Dr.  Gibb,  in  his  work  on  diseases  of  the  throat,  states  that 
he  has  seen  this  disease  in  a  very  exaggerated  form  in  photo- 
graphers, and  in  persons  nmch  exposed  to  the  fnmes  of  acrid 
chemicals  in  coniined  chambers,  and  that  its  ol)stinacy  in  them 
is  quite  remarkable.  We  should  imagine  the  obstinacy  of  the 
affection  to  be  due  to  the  persistence  with  which  such  individ- 
uals are  constantly  exposed  and  re-exposed  to  the  exciting 
cause.  If  their  occupations  could  be  changed,  the  disease 
would  probably  be  found  more  manageable. 

The  I'eason  of  its  prevalence  among  clergymen  is,  at  least  in 
part,  due  to  the  inequalities  of  temperature  ander  which  they 
are  often  compelled,  to  preach  ;  with  head,  often  sparsely  cover- 
ed with  hair,  exposed  to  draughts  from  open  windows,  or  the 
open  air,  at  the  moment  that  they  are  using  the  organs  of  the 
throat  in  addressing  their  auditors,  and  thus  exposing  these 
parts  also  to  the  influence  of  cold  air  which  has  not  been  warm- 
ed by  previous  passage  through  the  nostrils.  Preaching  in  a 
cold  church  is  sometimes  an  excitins:  cause. 

I  ha^'e  known  more  than  one  academic  lecturer  who  con- 
tracted a  chronic  pharyngitis  every  autumn  from  the  access  of 
currents  of  air  from  open  windows  striking  upon  a  bald  head, 
and  in  which  the  use  of  a  skull-cap  during  exposure  secured 
immunity  from  the  attack. 

It  has  been  stated  by  some  authors  that  the  Catholic  clergy 
are  less  liable  to  this  form  of  disease  than  clergymen  of  other  per- 
suasions, and  that  the  greater  liability  of  the  latter  class  is  in 
great  part  attributable  to  their  more  frequent  habit  of  leaning  over 
the  pulpit  to  read  their  discourses,  thus  compressing  the  muscles 
of  the  thorax  and  abdomen  at  a  time  when  their  unimpeded 
action  is  desirable  ;  and  that 'the  immunity  in  the  other  class  is 
due  to  their  preaching  extemporaneously,  and  thus  maintaining 
the  erect  posture.  That  there  is  some  force  in  this  remark  we  may 
be  very  willing  to  admit,  but,  as  far  as  my  own  experience  is  con- 
cerned, there  has  been  no  evidence  of  immunity  in  this  resjDcct 
for  the  Catholic  clergy. 

Yery  often  the  only  apparent  cause  is  a  depressed  state  of 
mind,  from  domestic  and  pecuniary  troubles,  or  the  effect  of 
prolonged  sedentary  and  harassing  professional  occupations. 


160  SPECIAL    AFFECTlOIfS    OF    THE    PHAEYNX. 

Tlie  appearances  of  the  parts  in  this  disease  are  very  charac- 
teristic, though  they  are  exceedingly  various. 

Perhaps  the  most  frequent  appearance  presented  is  that  of 
numerous  small  projections,  sometimes  circular  in  outline, 
sometimes  irregular,  varying  in  size  from  that  of  a  pin-head  to 
that  of  a  small  pea,  though  not  very  often  acquiring  the  latter 
dimensions,  esj)ecially  in  cases  of  comparatively  short  duration. 
Their  color  is  a  deeper  red  than  that  of  the  surrounding  mucous 
tissue,  which  is  also  deeper  in  tint  than  is  normal.  These  pro- 
minences are  isolated  or  in  clusters.  They  are  more  apt  to  be  in 
clusters  at  the  latei-al  angles  of  the  pharynx,  though  frequently 
enough  so  on  the  posterior  wall  also.  These  prominences  com- 
prise enlarged  or  hypertrophied  glands,  enlarged  probably 
by  an  arrest  of  their  secretion,  which  has  no  longer  an 
outlet  on  account  of  the  swollen  condition  of  their  mouths, 
which  are  thus  blocked  up.  Sometimes  the  watery  matters 
of  the  secretion  being  reabsorbed,  there  remains  the  albu- 
minous portion,  to  which  additions  are  constantly  made ;  and 
very  often,  finally,  the  contents  have  a  cheesy  character,  which 
has  been  denominated  "  tubercular "  by  Prof.  Green,  and  are 
also  so  called  by  Gibb  and  many  others  who  have  followed  him 
in  his  description  of  the  complaint,  under  the  name  of  follicu- 
lar disease  of  the  throat  and  air-passages,^  or  follicul-ar 
disease  of  the  pharyngo-laryngeal  memhrane.  I  caimot,  how- 
ever, subscribe  to  the  opinion  that  the  contents  of  these  glands 
are  tuberculous  matter  in  that  form  of  complaint  under  consid- 
eration ;  though  it  does  sometimes  occur  that  tuberculous 
deposits  take  place  in  the  phar}'ngeal  mucous  membrane,  and 
they  may  even  undergo  the  metamorphosis  into  carbonate  of 
lime,  for  I  have  occasionally  seen  them  there,  and  in  one  or 
two  instances  removed  with  the  point  of  the  knife  small  cal- 
careous concretions  in  every  way  similar  to  those  concretions 
occasionally  expectorated  in  cases  of  pulmonary  tuberculosis. 

I  am  the  less  inclined  to  approve  of  the  term  tubercular  sore 
throat.,  which  is  employed  by  the  authorities  alluded  to,  as  a 
synonym  for  this  disease,  because  the  affection  has  been  known  to 

'  A  Treatise  on  Diseases  of  tlie  Air-Passages.     Xew  York  (4th  Edit.),  1858 


CHROjSTIC    rOLLICLTLAE    PHARYNGITIS.  161 

have  existed  for  many  years  without  being  accompanied  or  fol- 
lowed by  tuberculous  phthisis,  a  result  which  conld  hardly  be 
avoided  in  the  prolonged  persistence  of  a  disease  really  tubercu- 
lous in  character.  It  is  true  that  tuberculous  consiunption  is 
preceded  in  some  instances  by  chronic  follicular  disease  of  the 
mucous  covering  of  the  pharynx  and  larynx  ;  but  this  condition 
may  have  produced  a  predisposition  to  tuberculous  disease, 
evidences  of  which  ultimately  make  their  appearance  in  the 
follicles  or  in  the  mucous  membrane  as  an  expression  of  the 
general  condition  of  system  which  has  ensued. 

There  is  usually  a  narrow  liiie  of  redness  about  the  base  of 
these  enlargements ;  and  sometimes  the  patches  in  which  they 
occur  are  so  close  to  each  other,  that  the  accumulated  red 
lines,  by  which  they  are  bordered,  appear  mapped  out  into  ir- 
regular spaces  for  the  reception  of  the  enlarged  masses.  The 
ordinary  transparent  exhalation  which  bathes  the  mucous  mem- 
brane in  the  healthy  condition  is  superseded  by  mucus,  which  is 
often  adherent,  here  and  there,  in  viscid  clumps.  In  some  j)arts 
of  the  membrane  not  yet  invaded  by  the  diseased  action,  the 
normal  exhalation  will  have  become  collected  into  minute  drops 
which  appear  like  groups  of  vesicles,  and  have  often  been  mis- 
taken for  herpetic  eruptions,  similar  to  those  which  sometimes 
precede  ordinary  membranous  sore  throat.  The  interspaced 
mucous  membrane  in  the  vicinity  of  these  patches  of  drops  of 
moisture,  appears  sunken  in  by  contrast,  and  the  general  aspect 
is  that  "  slightly  raw  and  granulated  appearance "  so  much 
spoken  of  in  the  books.  In  this  form  of  the  disease  there  is  no 
rawness;  the  loss  of  epithelium  is  merely  Pig_  35^ 

apparent,  and  the  vesicles  can  all  be  wiped 
off  with  a  soft  spouge,  showing  the  mem- 
brane beneath  to  be  in  a  healthy  condition. 
Similar  apparent  vesicles  are  often  seen  up- 
on the  root  of  the  uvula  and  upon  the  soft  pal- 
ate, which  structures  are  sometimes  the  seat 
also  of  small  groups  of  enlarged  glands  ; 
and  occasionally  they  occupy  the  edges  of 
the  arches  of  the  palate,  giving  its  border 
an  une^  en  appearance.  The  tonsils  are  not  roiiictuar  pharyngitis, 
11 


162  SPECIAL    AFFECTIOlSrS    OF    THE    PHAEYIiX. 

aj)t  to  be  affected  in  this  stage  of  the  complaint ;  nor  the 
U'snila  to  be  elongated.  It  is  difKcnlt  to  depict  the  appear- 
ances which  have  just  been  described,  but  an  attempt  has  been 
made  to  do  so  in  Fig.  35,  in  which  the  enlarged  follicles  are  well 
seen. 

At  this  stage  of  the  disease  there  is  only  a  moderate  sense  of 
amioyance  in  the  throat,  a  little  expectoration  of  "^dscid  mucus 
at  times,  but  no  cough.  Xor  is  the  voice  much  affected,  except 
perhaps  after  long  or  continued  use  ;  and  then  power  is  regained 
by  a  rest  of  a  day  or  two.  The  larjmx  will  show  signs  of  irrita- 
tion, with  congestion  of  the  vocal  cords  after  the  use  of  the 
voice,  but  not  during  the  intervals.  Thus,  supposing  the  patient 
a  clergyman  who  preached  on  the  Sunday ; — on  Saturday  his 
larynx  will  have  appeared  normal,  on  the  Monday  it  will  be 
congested.     The  active  disease  is  confined  to  the  pharynx. 

When  the  disease  has  progressed  further,  we  find  that  the  fol- 
licles have  become  still  more  enlarged.  A  more  viscid  nnicus 
adheres  to  the  parts  and  in  greater  quantity ;  and  upon  the  upper 
portion  of  the  posterior  wall,  behind  the  soft  palate,  we  often 
find  irregular  patches  of  concreted  mucus  which  have  gradually 
fallen  down,  or  been  hawked  down  fi-om  the  enlarged  follicles 
existing  at  the  upper  portion  of  the  pharynx,  the  glandular  tissue 
at  the  vault  of  the  phai-}Tix  having  participated  in  the  disease. 
Sometimes  strings  of  this  mucus  will  hang  down  from  the  pos- 
terior wall  of  the  soft  palate,  showing  that  the  nasal  asj)ect  of 
the  palate  and  perhaps  the  posterior  nares  arealso  invaded  by  the 
diseased  action.  The  patches  of  groups  of  enlarged  follicles  will 
have  become  much  larger,  and  almost  always  longer  than  they  are 
broad,  but  presenting  great  differences  in  this  respect.  Their  sur- 
face is  often  velvety,  and  to  the  touch  they  are  elastic.  The  isolated 
follicles  will  be  apt  to  have  become  ulcerated,  and  small  whitish 
masses  of  mucus  will  hang  down  from  them  upon  the  mucous 
membrane,  and  become  coalesced  with  similar  masses  from  en- 
larged follicles  below.  Sometimes  these  follicles  will  present  the 
appearance  of  inflamed  pustules  on  the  point  of  bursting.  In 
the  interspaces  irregular  spots  of  superficial  ulceration  will  be 
seen  showing  a  destruction  of  the  epithelial  layer  of  the  mucous 
membrane.     The  uvula  is  apt  to  have  become  elongated,  and  its 


CHROmC    FOLLICULAE    PHARYI^GITIS.  163 

surface  as  well  as  the  surface  of  the  velum  will  be  more  thickly 
studded  with  enlarged  glands,  though  they  are  not  as  apt  to  be 
ulcerated  as  are  those  of  the  pharynx.  At  other  times  groups 
of  real  vesicles  will  be  observed  on  the  soft  palate  and  the  uvu- 
la ;  often  arranged  more  or  less  linearly,  on  each  side  of  the 
raphe.  The  tonsils,  too,  will  have  become  irregularly  enlarged, 
and  often  exliibit  upon  their  surface  superficial  ulcerations, 
covered  with  a  grayish  or  whitish  secretion.  A  common  ap- 
pearance presented,  when  the  affection  is  of  long  standing,  is 
depicted  in  Fig.  36. 

The  symptoms  of  hoarseness,  expectoration,  and  dysphagia 
will  all  be  increased  in  severity, 
and   cough  will   be   present  in  a  -^- ' 

greater  or  less  degree.  The  larynx 
will  be  found  to  exhibit  the  evi- 
dences of  chronic  inflammation  of 
its  mucous  membrane,  to  be  de- 
scribed in  detail  under  the  head  of 
chronic  laryngitis.  When  the 
tongue  is  well  depressed,  the  ap- 
pearances mentioned  will  be  found 
to  exist  to  some  extent  in  the  lower 
portion  of  the  pharynx. 

As  the  disease  progresses  the  in- 
flamed follicles  ulcerate,  the  sur- 
faces of  the  ulcers  becoming  coat-  

.  Chronic  follicular  pharj-ngitis. 

ed  with  a  grayish  secretion  which 

trickles  down  over  the  surface  of  the  membrane.  The  angles 
of  the  pharynx  are  quite  prone  to  be  the  seat  of  ulceration,  and 
this  sometimes  extends  along  the  walls  of  the  pharyngo-laryn- 
geal  or  pyramidal  sinuses,  quite  to  the  entrance  of  the  oesopha- 
ffus.  The  follicles  at  the  base  of  the  tono-ue,  which  are  often 
much  enlarged,  sometimes  become  ulcerated  in  like  manner,  as 
does  also  the  mucous  membrane  covering  the  glosso-epiglottic 
sinuses  at  the  sides  of  the  glosso-epiglottic  ligament.  The  secre- 
tion from  all  these  surfaces  becomes  purulent ;  sometimes  san- 
guinolent  from  rupture  of  superficial  blood-vessels. 


164  SPECIAL    AFFECTIONS    OF    THE    PHAEYJSTX. 

The  voice  is  sometimes  affected  in  this  disease,  without  any 
visible  implication  of  the  laryngeal  structures,  apj)arently  re- 
sulting merely  from  an  extension  of  the  nervous  influence  of  the 
pneumogastric  nerve.  This  is  evident  from  wliat  is  frecjuently 
observed  to  occur  in  public  speakers.  They  gradually  become 
hoarse  during  a  prolonged  or  energetic  harangue,  and  relieve 
the  hoarseness  at  once  by  swallowing  a  little  water.  Now  the 
water  goes  down  the  gullet,  and  not  into  the  larynx.  True,  a 
little  water,  but  a  very  little  indeed,  does  sometimes  trickle 
into  the  larynx  down  the  inter-arytenoidal  fold,  but  it  is  hardly 
enough  to  moisten  the  vocal  cords  and  larjaigeal  mucous  mem- 
brane sufficiently  to  account  for  the  improvement  in  voice 
which  follows  the  act.  We  have  to  fall  back  upon  the  theory 
that  the  impression  made  upon  the  divisions  of  the  pneumo- 
gastric nerve  distributed  to  the  phar^mx,  cesophagus,  and 
stomach,  is  propagated  to  those  other  branches  distnbuted-  to 
the  larynx.  In  the  same  manner,  a  pharyngeal  irritation 
will  produce  hoarseness  in  a  larynx  apparently  healthy  in  every 
respect.  This  I  have  seen  again  and  again ;  and  have  often 
seen  it  follow  the  application  of  nitrate  of  silver  to  the  surface 
of  but  one  or  two  groups  of  enlarged  pliaryngeal  follicles ;  as 
well,  also,  as  result  from  a  more  extensive  cauterization  of  the 
pharynx.  This  would  seem  to  confirm  the  view  of  Prof. 
Green,  that  the  relation  of  the  pliarynx  with  the  respiratory 
passages  is  more  intimate  and  important  than  its  relation  with 
the  cesophagus ;  speaking  in  a  pathological  sense  rather 
than  an  anatomical  one.  In  these  cases  the  voice  becomes 
veiled  at  times,  then  muffled  and  hoarse  ;  these  symptoms  con- 
tinuing, it  becomes  a  matter  of  difficulty  to  speak  in  a  clear, 
distinct  tone,  and  the  effort  is  painful,  the  pain  running  from 
the  region  of  the  hyoid  bone  upwards  on  both  sides.  Tlie 
voice  may  be  a  deep  bass  in  the  morning,  and  gradually  rise 
to  a  shrill  screech  in  the  course  of  the  day.  Sometimes  con- 
tinued efforts  to  speak  result  in  complete  aphonia  for  the 
remainder  of  the  day.  At  other  times  the  patient  wakes 
up  in  the  morning  aphonic  or  dysphonic,  and  as  he  engages  in 
conversation  his  voice  becomes  gradually  stronger,  until  towards 
the  middle  of  the  day  it  is  almost  natural  in  timbre,  except 
that  it  is  a  little  hoarse. 


CHROlSnC    FOLLICULAR    PHARYNGITIS.  165 

The  subjects  of  these  cases  are  usually  such  as  have  ont-door 
employments  requiring  the  use  of  the  voice.  It  is  not  found 
so  much  in  those  who  speak  in-doors,  unless  tliere  is  a  distinct 
laryngeal  complication.  We  therefore  meet  it  in  military  and 
naval  officers,  itinerant  venders,  conductors,  newsboys,  shop- 
keepers, and  the  like.  If  the  affection  is  allowed  to  progress 
unrestrained,  the  larynx  is  sure  to  become  involved  eventually, 
and  may  then  become  more  seriously  aifected  than  the  pharynx 
was  in  the  first  instance. 

The  diagnosis  is  easy  by  ordinary,  and  by  laryngoscopic  in- 
spection of  the  throat. 

During  the  treatment  of  these  cases  the  use  of  the  voice 
should  be  interdicted,  if  possible,  until  the  disease  of  the 
jiharynx  is  well  under  control.  Where  the  nature  of  the 
patient's  occujDation  is  such  that  necessity  compels  the  use 
of  the  voice,  care  must  be  taken  to  make  the  least  use  of  it  pos- 
sible under  the  circumstances,  with  the  avoidance  of  prolonged 
talking  at  any  one  time.  In  order  to  secure  compliance  with 
an  injunction  of  this  kind,  the  patient  should  be  distinctly 
informed  that  the  use  ^f  the  vocal  organs  during  the  treatment 
will  greatly  retard  any  progress  towards  a  cure.  It  is  the  im- 
possibility, in  many  instances,  of  securing  rest  to  the  parts 
that  renders  their  treatment  protracted  and  very  often  unsatis- 
factory. The  habitual  use  of  demulcent  lozenges,  such  as  those 
composed  of  the  Iceland  moss  or  the  marsh-mallow,  will  often 
afford  a  good  deal  of  relief  and  help  to  allay  the  irritability  of 
the  pneumogastric  nerve.  They  can  be  made  up  by  the 
confectioner  in  the  form  of  gum-di'ops  without  the  addition  of 
sugar.  Occasionally  it  may  be  advantageous  to  have  a  small 
quantity  of  lactucarium  or  coninm  incorporated  into  the  mass, 
but  then  some  restriction  ]nust  be  made  as  to  the  frequency  of 
their  use. 

The  fuaction  of  SAArallo-wing  is  often  impaired  in  this  affec- 
tion, and  sometimes  to  such  an  extent  as  to  be  always  attended  with 
pain  or  with  the  production  of  sensations  of  a  spasmodic  character. 
At  times  there  may  even  exist  an  inability  to  swallow.  This 
dysphagia,  in  some  instances,  appears  to  be  altogether  of  a  ner- 


166  SPECIAL    AFFECTIOJS^S    OF    THE    PHAFvYNX. 

vous  character,  and  in  these  cases  j)articularlj,  though  also  in 
others,  there  may  be  unpleasant  and  even  painful  sensations 
similar  to  those  produced  by  swallowing,  independently  of  any 
act  of  deglutition.  It  is  said  that  at  times  the  spasm  will 
amount  to  that  of  actual  stricture,  and  that  it  will  sometimes  be 
impossible  to  introduce  the  sound,  under  such  circumstances, 
without  an  amount  of  force  which  w^ould  not  be  justifiable ;  but 
I  have  not  as  yet  encountered  any  cases  of  this  nature.  These 
cases  are  not  instances  of  the  ordinary  spasinodic  stricture  of 
the  ossophagus,  which  is  unaccompanied  with  chronic  pharyn- 
gitis as  an  essential  element  of  the  disorder,  and  which  usually 
yields  very  readily  to  the  introduction  of  the  sound. 

Generally  the  dysphagia  is  experienced  only^  in  swallowing 
hard  and  solid  food  ;  and  by  eating  slowly  and  taking  care  to 
masticate  each  morsel  thoroughly,  so  that  it  becomes  well  in- 
corporated with  a  sufiicient  amount  of  saliva,  deglutition  can  be 
rendered  much  more  comfortable.  Some  patients  experience 
so  much  trouble  and  uneasiness  in  swallowing  even  well-masti- 
cated food,  that  they  resort  in  great  measure  to  spoon  food  or 
liquid  diet. 

In  some  cases  of  dysphagia,  where  the  affection  has  been  of 
long  standing,  we  observe  a  condition  of  the  structures  which  in 
part  accounts  for  it.  We  see  a  number  of  ulcerated  places  in 
various  portions  of  the  pharyngeal  mucous  membrane,  these 
being  irregular  in  outline,  though  more  or  less  ovoidal  in  con- 
figuration, and  being  separated  by  continuous  divisions  of  un- 
abraded  membrane,  so  that  the  patches  of  ulceration,  when  nu- 
merous and  not  yet  run  into  each  other,  give  somewhat  the  ap- 
pearance of  the  interspaces  of  a  network.  The  continuous 
stripes  of  mucous  membrane  are  usually  of  a  pale,  yellowish 
color ;  the  ulcerated  spots  have  a  fine  red-lined  margin,  and  in 
some  of  the  interspaces  which  have  not  as  yet  undergone  erosion, 
we  see  prominent  red  patches  of  hypertrophied  glands  and 
connective  tissue. 

In  other  cases  the  dysphagia  seems  to  be  due  to  a  loss  of 
muscular  contractility,  from  absolute  atrophy  of  the  muscular 
tissue,  or  to  a  partial  paralysis  from  infiltration  between  the  mus- 
cular fibres.     In  these  cases  the  posterior  phai-yngeal  wall  ap- 


CHEOIS^IC    EOLLICULAE    PHARYNGITIS.  167 

pears  to  be  arranged  in  more  or  less  regular  vertical  folds,  render- 
ed more  prominent  than  tliey  really  are  by  reason  of  the  divisions 
dijDping  down  between  them.  These  ridges  are  due  to  hypertro- 
phic swelling  of  the  connective-tissue  sheaths  of  the  muscular 
fibres,  over  which  the  mucous  membrane  sometimes  becomes  so 
much  atrophied  as  to  admit  of  the  detection  of  the  muscular  striae 
beneath  it.  Moreover,  we  find  that  there  is  sometimes  an  actual 
atroph}^  of  the  muscular  tissue,  so  that  the  cavity  of  the  pharynx 
is  abnormally  deep,  and  this  excavation,  as  it  w,ere,  is  often  con- 
fined to  one  side,  most  frequently  the  right  side,  according  to 
my  own  observations.  The  condition  of  things  is  sucli  at 
times  as  to  convey  the  idea  of  a  want  of  symmetry  of  the  two 
sides  of  the  spinal  column,  the  outline  of  the  constituents  of 
which  is  sometimes  distinctly  discernible  through  the  atrophied 
tissues.  Sometimes,  indeed,  the  closest  examination,  aided  by 
palpation  with  the  finger,  has  led  to  the  conclusion  that  there  was 
present  either  a  case  of  absorption  of  the  connective  tissue  be- 
tween the  pharynx  and  cervical  vertebrae,  as  well  as  of  the 
muscular  tissue  itself,  or  else  a  congenital  prominence  of  one 
side  of  the  spinal  column.  In  addition  to  this  striated  appear- 
ance of  the  posterior  pharyngeal  wall,  the  parts  may  be  stud- 
ded with  hypertrophied  glands,  intact  or  in  process  of  ulcera- 
tion, and  accompanied  with  either  a  sound  or  eroded  condition 
of  the  intervening  tissue. 

Impairment  of  hearing  is  at  times  an  attendant  upon 
chronic  follicular  pharyngitis,  and  this  impairment  is  sometimes 
of  a  permanent  character.  Disease  of  the  pharyngeal  mucous 
membrane  is,  in  fact,  a  very  frequent  cause  of  disease  of  the 
organ  of  hearing,  especially  of  disease  of  the  middle  ear,  which 
very  often  has  its  origin  in  a  catarrhal  inflammation  of  the  naso- 
pharyngeal mucous  membrane.  The  lower  portion  of  the  mu- 
cous membrane  lining  the  Eustachian  tube,  being  continuous 
with  the  mucous  membrane  of  the  pharynx,  without  any  line 
of  demarcation,  is  very  apt  to  take  part  in  inflammatory  affec- 
tions of  the  pharynx,  especially  when  occupying  that  portion  in 
proximity  to  the  orifice  of  the  tube.  Every  inflammation  occur- 
ring in  this  way  is  apt  to  be  propagated  along  the  tube,  and  thus 


168  SPECIAL    AFFECTIONS    OF    THE   PHAEYJSTX. 

to  affect  the  structures  of  the  middle  ear.  When  there  is 
chronic  thickening  of  these  parts,  or  even  of  the  soft  palate, 
the  free  opening  of  the  Eustachian  tube  may  be  so  pressed  upon 
as  to  exclude  the  access  of  air  into  the  interior  of  the  middle 
ear,  and  thus  lead  to  disease  as  a  result  of  simple  mechanical 
obstruction,  without  any  active  participation  whatever  in  the 
disease  of  the  pharynx.  And  even  when  the  soft  palate  is  not 
affected  in  this  manner,  the  posterior  palatine  arch  may  be 
pushed  backwards  by  an  enlarged  tonsil  in  such  manner  as  to 
produce  a  similar  occlusion  of  the  orifice  of  the  tube.  The  re- 
lations of  the  pharynx,  the  palate,  and  its  j)osterior  arch  to  the 
pharyngeal  orifice  of  the  Eustachian  tube  may  be  well  studied 
in  the  representations  given  of  rhinoscopic  images. 

The  Eustachian  tube,  as  it  were,  pushes  through  the  posterior 
portion  of  the  lateral  wall  of  the  pharynx  for  the  distancje  of  a 
centimetre  or  a  centimetre  and  a  half,  just  in  front  of  the 
posterior  wall  of  the  pharynx,  leaving  a  sort  of  recess  between 
its  posterior  margin  and  the  junction  of  the  posterior  and  lateral 
walls  of  the  pharynx,  known  anatomically  as  the  recessus  ])ha- 
ryngis  lateralis,  or  fossa  of  Hosenmiiller,  the  depth  of  which 
therefore  depends  upon  the  length  of  the  tube  projecting  into 
the  pharynx.  This  fossa  is  usually  exceedingly  distinct ;  but  as 
a  result  of  infiammation  of  the  mucous  membrane,  adhesions 
take  place  between  the  two  sides  and  produce  bands  of  tissue 
which  stretch  from  one  side  of  the  fossa  to  the  other.  In 
some  cases  the  adhesion  of  the  nmcous  membrane  is  continu- 
ous, so  that  the  sulcus  becomes  obliterated,  and  there  is  no 
fossa  of  Rosenmliller  at  all.  A  similar  obliteration  may  also 
exist  as  a  result  of  hypertrophy  of  the  glandular  tissue,  ofttimes 
so  profuse  in  this  situation. 

Inflammation  of  the  pharyngeal  mucous  membrane  covering 
the  tube  may  be  very  easily  propagated  around  its  edges  into 
the  interior  of  the  tube,  and  thus  lead  to  deposits  aud  accumu- 
lations of  mucus  or  lymph  Avhich  by  their  mere  presence,  or 
b}^  producing  organic  obstruction,  prevent  a  maintenance  of 
due  atmospheric  pressure  on  both  sides  of  the  tympanic  mem- 
brane, and  thus  lead  to  impairment  of  hearing  from  disease  of 
the  tube  or  of  the  middle  ear  itself. 


CHEONIC    JFOLLICULAE   PHAEYlSrGITIS.  169 

Uneasy  sensations  in  the  throat  exist  almost  invariably  to  a 
greater  or  less  extent,  and  they  are  described  by  patients  in 
varions  manners.  Some  complain  of  pricking  sensations ; 
others  of  a  feeling  as  if  there  were  a  hair  or  a  bristle  that  they 
could  not  get  rid  of ;  many  complain  of  heat  and  burning. 

An  elongated  uvula,  frequently  coexistent  with  chronic  fol- 
licular pharyngitis,  often  gives  rise  to  distressing  symptoms; 
although  there  are  many  cases  of  considerable  elongation  of 
this  structure,  even  when  it  is  long  enough  to  lie  a  short  dis- 
tance upon  the  base  of  the  tongue,  which  are  not  at  all  attended 
by  any  of  the  symptoms  usually  indicative  of  this  condition. 
All  the  ordinary  subjective  symptoms  of  phthisis  are  said  to 
have  been  produced  in  many  instances  by  a  simple  elongation 
of  the  uvula ;  not  only  cough,  but  expectoration,  and  that  not 
only  mucous  in  character,  but  of  a  purulent,  and  even  a  san- 
guinolent  character ;  attended  with  acceleration  of  the  pulse, 
hectic  fever,  and  emaciation.  It  is  likely  that  these  latter  symp- 
toms are  not  directly  attributable  to  the  elongation  of  the  uviila, 
but  to  the  depressing  mental  effect  of  a  belief  in  the  existence 
of  pulmonary  consumption  on  the  part  of  the  patient.  This 
elongation,  in  most  instances,  does  not  include  the  muscular 
structure  of  the  organ,  but  is  limited  to  its  mucous  membrane 
and  the  submucous  connective  tissue,  which,  being  greatly  re- 
laxed, form  a  sort  of  pouch  filled  with  a  serous  or  a  sero-plastic 
infiltration  below  the  azygos  muscle.  Sometimes  the  mucous 
membrane  forms  a  sort  of  thin  caudal  extremity  attached  to  the 
body  of  the  uvula.  Where  the  muscle  itself  is  the  seat  of  the 
infiltration,  there  is  usually  an  increase  in  the  transverse  portion 
of  the  uvula,  forming  a  condition  of  general  hypertrophy  and 
not  elongation  merely. 

Professor  Green  mentions  a  case  in  which  an  enlaro-ed  and 
elongated  uvula  was  over  two  inches  in  length,  and  nearly  half 
an  inch  thick  at  its  largest  diameter. 

•  A  special  form  of  chronic  pharyngitis  attended  by  a  constant 
irritation  in  the  throat,  with  a  feeling  of  dryness,  is  that  to 
which  the  name  pharyngitis  sicca  has  been  given.  It  is  charac- 
terized by  a  dry  and  glossy  or  highly  polished  appearance  of 


170  SPECIAL   ATFECTIOlSrS    OF    THE    PHARYNX. 

the  mucous  membrane.  The  mucous  membrane  deprived  of 
its  complement  of  moisture  becomes  an  exceedingly  thin  layer, 
and  enables  us  to  perceive  the  striae  of  the  constrictor  mus- 
cles beneath  it. 

Particles  of  dust  fi'om  the  street  or  ^vorkshop  are  apt  to  ac- 
cumulate on  this  dry  glossy  meml^rane,  and  as  there  is  no 
secretion  present  to  assist  in  their  dislodgement,  they  become 
constant  sources  of  irritation. 

This  condition  is  rarely  met  with  in  young  people,  but  often 
exists  in  middle  adult  life,  and  still  more  fi'equently  in  elderly 
subjects. 

Great  relief  is  obtained  by  supplying  to  the  parts  that  mois- 
ture in  which  they  are  deficient.  This  is  to  be  done  by  the 
internal  administration  of  remedies  which  excite  the  secretion 
from  mucous  membrane :  such  as  cubebs,  and  other  articles  of 
its  class ;  muriate  of  ammonia  in  small  doses ;  iodide  of  potas- 
sium when  not  contra-indicated.  The  frequent  inhalation  of 
the  steam  from  hot  water  will  moisten  the  parts,  and  to  a  cer- 
tain extent  invite  the  local  action  of  the  systemic  remedy ;  a 
process  which  is  assisted  still  further  by  the  frequent  topical 
application  of  glycerine. 

The  treatraent  of  chronic  follicular  pharyngitis  is  not  always 
as  successful  as  one  would  expect.  This  arises  in  part  from 
the  fact  that  the  affection  is  rarely  severe  enough  to  induce  the 
patient  to  follow  strictly  the  advice  of  his  physician.  The  affec- 
tion, being  eminently  a  chronic  one,  requires  chronic  treatment, 
and  this  the  patient  is  unwilling  to  submit  to.  Again,  inasmuch 
as  the  general  health  is  often  unimpaired,  that  is,  as  far  as 
ability  to  continue  at  one's  employment  is  concerned,  avoidance 
of  exposure  to  the  causes  of  the  affection  cannot  1)e  secured. 
This  is  especially  the  case  with  those  who  gain  their  livelihood 
in  great  measure  by  the  exercise  of  the  voice.  It  is  only  when 
totally  incapacitated  for  work  that  they  submit  to  treatment, 
and  then  the  mental  depression  under  which  they  labor  places  a 
fresh  impediment  in  the  path  of  cure. 

Constitutional  and  local  ti'eatment  are  both  required  in  these 
cases.     Tlie  functions  of  the  skin,  bowels,  and  other  organs  must 


CHEOJSTIC    FOLLICULAE   PHAEYjSTGITIS.  171 

be  maintained  in  as  normal  a  condition  as  possible,  by  attention 
to  cleanliness,  clothing,  diet,  and  temperatnre ;  and  when  hy- 
gienic observances  are  insnfficient,  medicinal  agents  are  to  be 
resorted  to  for  the  purpose.  Placidity  of  mind  is  an  important 
feature  in  the  treatment  of  clergymen,  vocalists,  and  public 
speakers.  Tonics,  such  as  iron  and  cpiinine,  are  often  required; 
and  vei-y  often  nnich  benefit  will  result  from  the  employment 
of  phosphoric  acid  or  some  of  its  compounds.  I  have  found 
23hosphoric  acid  a  remedy  often  equal  to  the  control  of  nervous 
depression,  and  not  infrequently  a  promoter  of  the  appetite  and 
digestion.  The  acid  phosphate  liquor  pre]3ared  by  Horsford 
has  been  very  satisfactory  in  my  hands  for  this  purpose,  and  I 
have  prescribed  it  frequently  during  the  last  two  years.  It  is 
administered  once  or  twice  a  day  in  teaspoonf  ul  doses,  dissolved 
in  a  large  goblet  of  water  and  sweetened  to  the  taste.  It  forms 
a  palatable  acidulous  drink,  much  relished  by  many  patients ; 
and  its  beneficial  effects  usuall}'  show  themselves  within  a  fort- 
night. 

Local  treatment  seems,  in  most  cases,  absolutely  necessary  to 
effect  riddance  of  the  local  trouble.  Sometimes  the  effects  are 
very  prompt,  and  sometimes  they  are  very  slow.  Even  in  cases 
where  local  treatment  does  not  appear  to  induce  any  diminution 
in  the  size  of  the  enlarged  follicles,  the  benefit  of  the  treatment 
in  the  relief  of  the  subjective  symptoms  is  often  marked.  In 
some  cases  no  treatment  whatever  seems  to  have  any  beneficial 
effect  on  the  symptoms.,  subjective  or  objective. 

The  most  favorite  and  fashionable  local  treatment  for  chronic 
follicular  pharyngitis  consists  in  the  topical  application  of  the 
nitrate  of  silver  ;  and  although  this  method  is  much  derided  by 
some  authors,  there  is  no  doubt  that  it  is  more  efficacious  than 
any  other  treatment  they  have  suggested  in  substitution.  Much 
depends  upon  the  manner  of  application.  This  should  be  done 
slowly  and  carefully,  and  not  in  the  off-hand  way  in  which  it  is 
so  fi-equently  performed,  gagging  the  patient  and  slopping  it 
over  structures  which  it  was  not  intended  to  touch.  The  pha- 
rynx should  be  washed  out  by  syringe  or  mop  before  the  nitrate 
of  silver  is  applied.  This  detaches  the  clumps  of 'mucus  adher- 
ing to  the  mucous  membrane,  and  provides  a  clean  surface  for  the 


172  SPECIAL    AFFECTIONS    OF    THE    PHAEYNX. 

deposition  of  the  application,  a  yery  important  point  which  is 
not  often  attended  to.  The  nitrate  of  silver  is  usually  applied 
in  solution — a  large  sponge-mop  or  a  brush  being  saturated 
with  it — and  then,  after  shaking  off  the  superabundant  liquid, 
swabbed  over  the  parts  as  rapidly  as  possible,  the  tongue  being 
depressed  by  means  of  a  tongue-depressor,  the  handle  of  a  spoon, 
or  some  other  contrivance.  A  much  better  plan  is  to  employ  a 
small  hair-pencil,  or  a  very  small  piece  of  soft  sponge,  held  in 
a  pair  of  forceps,  and  to  touch  the  hypertrophied  follicles  and 
the  ulcerated  spots,  one  after  another,  gently,  carefully,  and 
effectually.  Enough  of  the  fluid  for  the  purpose  will  distribute 
itself  over  the  adjacent  membrane.  To  do  this  thoroughly  may 
require  several  introductions  of  the  instrument,  a  proceeding 
occupying  a  little  time,  to  be  sure,  but  one  not  so  apt  to  be 
attended  by  gagging  or  spasms  of  suffocation,  and  much  more 
apt  to  be  beneficial  in  its  effect.  The  nitrate  of  silver  forms 
with  the  membrane  an  impermeable  coating,  which  not  only 
protects  the  parts  from  the  air,  and  the  secretions  of  the  mouth, 
but  exercises  a  gentle  compression  upon  the  enlarged  follicle. 

A  solution  varying  from  forty  to  sixty  grains  to  the  ounce 
may  be  used  in  the  first  instance,  and,  if  deemed  advisable,  its 
strength  may  be  increased  to  one  hundred  and  twenty,  or  even, 
in  some  instances,  four  hundred  and  eighty  grains  to  the  ounce, 
which  represents  a  saturated  solution.  The  stronger  solutions, 
as  well  as  the  solid  stick,  are  used  when  it  is  desired  to  produce 
destruction  of  the  tissue,  and  for  this  purpose  must  be  main- 
tained in  contact  for  some  seconds,  and  not  removed  immedi- 
ately, as  when  a  mere  antiphlogistic  or  alterative  effect  is  to  be 
produced  on  the  part.  Any  excess  of  the  nitrate  deposited  on 
the  part  may  be  removed  by  touching  it  promptly  with  a  solu- 
tion of  table  salt  or  with  milk.  Although  the  applications  of  the 
nitrate  of  silver  are  in  the  main  w^ell  borne,  they  sometimes 
produce  a  great  deal  of  distress,  occasionally  actual  spasm 
of  the  glottis,  even  when  carefully  performed,  and  without  any 
possibility  of  a  drop  of  the  fluid  having  fallen  into  the  larynx. 
For  this  reason  it  is  well,  when  making  an  application  to  the  parts 
for  the  first  thne,  to  test  their  sensibility  by  touching  a  single 
enlarged  follicle,  or  group  of  follicles,  and  then  proceeding  fur- 


CHEOIsnC    FOLLICULAR    PHARYlSrGITIS.  173 

ther  according  to  the  indications.  Tlie  application  is  to  be 
repeated  every  day,  or  every  two,  three,  or  four  days,  as  the  case 
may  seem  to  require. 

AVTien,  after  a  fair  trial  of  two  or  three  weeks,  these  applica- 
tions do  not  seem  to  be  of  any  nse,  tlie  plan  may  be  adopted  of 
splitting  each  follicle  with  the  point  of  the  knife,  and  then  press- 
ing the  edge  of  a  crystal  of  nitrate  of  silver,  finnly  secured, 
between  the  edges  of  the  wound.  In  this  way  we  bring  the  re- 
medy in  direct  contact  with  the  diseased  structure,  and  effect  its 
destruction  or  absorjDtion  more  promptly  than  when  the  appli- 
cation is  made  to  the  mucous  membrane  covering  it. 

The  chloride  of  gold  in  some  instances  forms  a  good  substitute 
for  the  nitrate  of  silver,  and  may.be  tried  when  the  latter  fails. 
It  is  used  in  solution  of  a  strength  varj^ing  from  fifteen  to  sixty 
grains  to  the  ounce. 

Chloride  of  zinc,  iodide  of  zinc,  sulphate  of  zinc,  sulj)hate  of 
copper,  and  many  other  remedies  have  been  proj)osed  as  substi- 
tutes for  nitrate  of  silver,  and  they  often  do  good  service;  but 
they  cannot  replace  it  in  the  majority  of  cases. 

In  addition  to  this  local  treatment,  the  projection  upon  the 
parts,  two  or  three  times  a  day,  of  sprays  of  weak  astringent 
solutions,  such  as  alum,  tannin  especially,  sulphates  of  zinc  or 
copper,  acetate  of  lead,  etc.,  do  excellent  service,  keeping  up  an 
astringent  effect  upon  the  tissues. 

In  obstinate  cases,  it  is  often  advisable  to  add  to  the  constitu- 
tional treatment  the  employment  of  iodide  of  potassium,  which 
will  sometimes  have  a  very  satisfactory  effect,  and  this  mil  be 
heightened,  in  certain  instances,  by  the  bichloride  of  mercury  in 
small  doses,  even  when  there  is  no  evidence  of  syphihtic  taint, 
and  independently  of  any  condition  of  that  kind. 

The  local  treatment  is  also  assisted  fi-equently  by  the  use  of 
blisters,  or  other  counter-irritation,  externally,  to  the  nape  of  the 
neck,  or  in  front  of  the  larynx. 

For  the  pain  and  local  annoyance,  lozenges  containing  opium, 
hyoscyamus,  conium,  lactucarium,  etc.,  or  chlorate  of  potassa, 
bromide  of  potassium,  muriate  of  ammonia,  and  the  like,  may 
be  allowed  to  dissolve  in  the  mouth  from  time  to  time.  Cho- 
colate forms  a  good  medium  for  the  lozenge. 


174 


SPECIAL    AFFECTIONS    OF    THE    PHARYNX. 


GLAKDTJLAE   HYPERTROPHY   AT    THE    VAULT    OF    THE   PHARYNX. 

The  glandular  tissue  at  the  vault  of  the  pharynx  is  apt  to 
take  on  simple  hypertrophy,  or  to  become  elongated  into  clus- 
ters of  hypertrophied  glands,  which  may  be  designated  as  folli- 
cular vegetations.  The  symptoms  of  this  affection  are  similar 
in  the  main  to  those  attending  a  protracted  coryza,  or  cold  in 
the  head,  except  that  there  is  very  little  discharge  of  mucus 
from  the  nostrils  ;  the  mucus  in  these  cases  being  expectorated 
through  the  mouth.  There  is  more  or  less  impediment  to  free 
nasal  respiration,  compelling  the  patient  at  times  to  keep  the 
mouth  opened  slightly  so  as  to  secure  freedom  of  breathing. 
Occasionally  there  will  be  impossibility  of  sleeping  on  one  side  or 
the  other,  from  stoppage  of  one  of  the  posterior  nasal  openings,  by 
the  dropping  or  falling  over  it  of  these  pendant  vegetations. 
There  will  be  a  feeling  of  fulness  at  the  posterior  portion  of  the 
nares  above  the  palate,  the  sensation  being  that  of  some  foreign 
material,  of  which  the  patient  endeavors  to  rid  himself  by  a  pe- 
culiar stridulous  nasal  inspiration,  so  as  to  drive  the  offending 
body  into  the  throat ;  this  movement  being  followed  by  a  hawk- 
ing and  spitting,  to  eject  whatever  may  have  been  driven  into 
the  pharynx.  The  expectoration  will  consist  of  lumps  of  mu- 
cus more  or  less  thickened,  and  sometimes  streaked  with  blood. 
In  marked  cases  of  the  affection,  there  will  be  a  deficiency  in  the 
enunciation  of  the  nasal  sounds  of  speech,  the  tones  of  m  and  n 
sounding  like  those  of  h  and  d.  If  the  disease  has  existed  for 
some  time,  some  disfigurement  in  the  external  conformation  of 
the  nose  may  have  ensued,  the  upper  portion  of  which  will  be 
compressed  from  side  to  side,  and  the  lower  portion  flattened  from 
before  backwards,  seeming  broader  than  it  really  is  from  the 
contrast  to  the  upper  portion.  In  some  cases  there  is  more  or 
less  impairment  in  hearing,  from  obstruction  of  the  pharyngeal 
orifice  of  the  Eustachian  tube.  This  deafness  is  sometimes 
associated  with  tinnitus  aurium.  Sometimes  there  will  be 
spitting  of  blood,  inasmuch  as  the  Aegetations  bleed  very 
readily  and  may  be  excited  to  hemoi-rhage  by  the  movements  of 
hawking. 


GLANDULAR  HTPERTROPHT  AT  VAULT  OF  PHAEYNX.   l75 

On  looking  into  the  throat,  there  will  usually  be  perceived  more 
or  less  e\idence  of  chronic  follicular  pharyngitis,  the  follicles 
being  enlarged  in  elongated  puffy-looking  masses ;  and  as  the 
palate  is  raised,  thick  clmnps  of  a  greenish-yellow  mucus  will 
often  be  seen  making  their  way  downward  upon  the  posterior 
wall  of  the  pharynx.  Masses  of  this  kind  are  often  hawked 
down  into  the  mouth  and  expectorated.  In  some  instances  the  pal- 
ate will  be  found  much  thickened,  especially  on  its  posterior  wall. 

The  existence  of  a  follicular  structure  at  the  roof  of  the 
pharynx  has  long  been  known.  Prof,  Green  speaks  of  it  in  his 
admirable  monograph  on  follicular  disease  of  the  pharyngo- 
laryngeal  membrane  ;  and  many  other  authors  mention  the  ex- 
istence of  a  mass  of  glandular  tissue  in  this  region,  which  is 
described  simply  as  a  chain  of  glands  extending  across  the 
pharynx  from  one  Eustachian  outlet  to  the  other.  The  impor- 
tance of  this  tissue,  however,  in  a  pathological  point  of  A-iew 
has  been  fully  recognized  only  since  the  introduction  of  the 
rhinoscope  as  an  instrument  of  diagnosis ;  and  a  number  of  cases ' 
are  recorded  by  Voltolini  and  others  in  which  the  disease  under 
consideration  was  unexj)ectedly  discovered  during  a  rhinoscopic 
examination,  either  for  disease  of  the  naso-pharyngeal  region, 
or  for  disease  of  the  ear  affecting  the  Eustachian  tubes.  In 
some  instances  the  condition  was  discovered  while  employing 
the  rhinoscope  to  ascertain  the  position  of  the  pharyngeal  orifices 
of  the  Eustachian  tube,  for  the  purpose  of  verifying  or  assisting, 
the  introduction  of  the  Eustachian  catheter. 

In  view,  therefore,  of  the  importance  of  the  subject,  and  the 
almost  universal  want  of  a  description  of  this  region  in  our 
works  on  anatomy,  it  is  to  be  hoped  that  it  will  not  be  out  of 
place  to  present  such  an  anatomical  description  here.  A  very 
good  account  by  Prof.  Ch.  Robin  will  be  found  in  the  Diction- 
naire  de  medecine  of  Nysten,  11th  (1855)  and  subsequent  edi- 
tions, under  the  o^ctioXQ  j)harynx. 

The  best  description,  however,  is  given  by  Prof.  Luschka,' 
who  has  recently  added  some  new  observations'  which  we  trans- 

'  Der  Schlundkopf  der  Menschen.     4to.    Tiibingen,  1868. 
^  Sur  le  tissu  adenoide  de  la  parte  nasale  du  pharynx  de  rhomme. — Journal 
de  VAnat.  et  de  la  Physiol. ,  1869.    No.  3.     May  and  June,  p.  225. 


176  SPECIAL    AFFECTIOJSrS    OY    THE    PHARYNX. 

late  for  tlie  benefit  of  our  readers,  iu  the  absence  of  any  other 
published  account  of  it  in  the  vernacular. 

"As  the  nasal  portion  of  the  human  23harynx  is  now  capable 
of  exposure  to  ocular  inspection  during  life,  an  exact  acquaint- 
ance with  the  normal  condition  of  the  walls  of  the  pharyngo- 
nasal  space  has  become  indispensable. 

"  Not  only  has  our  knowledge  of  this  region  been  hitherto  very 
imperfect,  but  it  has  even  been  impossible  to  establish  an  ac- 
cord between  the  diverse  oj)inions  maintained,  especially  as  re- 
gards the  nature  of  its  texture.  In  the  majority  of  treatises  and 
manuals  of  anatomy,  the  general  configuration  of  the  superior 
surface  of  the  vault  of  the  pharynx  itself  is  either  not  described 
at  all,  or  else  but  very  meagrely ;  authors  contenting  themselves 
by  repeating,  after  Kosenmiiller,  that  behind  the  pharyngeal 
orifice  of  the  Eustachian  tube,  the  mucous  membrane  forms  a 
depression  of  a  greater  or  less  depth. 

"  In  view  of  the  inaccessibility  of  this  region,  it  is  not  to  be 
wondered  at  that  so  few  facts  are  known  relative  to  its  patho- 
logical modifications. 

"  In  certain  maladies  which,  as  diphtheria,  extend  so  readily 
from  the  tissues  of  the  fauces  to  those  of  the  nasal  fossse,  there 
is  strong  presumption  that  the  adenoid  substance  of  the  vault 
of  the  pharynx  is  attacked  not  less  than  that  of  the  tonsils. 

"  For  the  prosecution  of  researches  of  this  nature,  a  method  of 
.examination  is  required  which  shall  permit  a  complete  explora- 
tion of  the  fully  exposed  vault  of  the  pharynx,  without  too  great 
a  mutilation  of  the  cadaver,  which  is  rarely  abandoned  to  the 
full  disposition  of  the  practitioner.  The  most  expeditious  pro- 
cedure, entailing  least  injury  to  the  cadaver,  is,  according  to  my 
experience,  as  follows : — 

"An  incision  is  made  under  the  jaw,  from  the  lobule  of  one 
ear  to  the  other ;  the  soft  parts  are  detached  from  the  iirferior 
maxilla  ;  and  then,  after  disarticulation  of  this  bone,  the  tissues 
forming  the  floor  of  the  buccal  cavity  are  separated  and  re- 
moved, together  with  the  palate  and  adjacent  segments  of  the 
septum  of  the  nasal  fossse.' 

1  Hubert  von  LuscKka.     Der  ScMundkopf  des  Mensehen.     Tubingen,  1868, 

4to.  p.  4  et  seq.,  pi.  i.  ad  xii. 


GLANDULAE  HYPEETKOPHY  AT  VAULT  OF  PHAPvNYX.      177 

"  The  internal  surface  of  the  vault  of  the  pharynx  thus  exposed 
is  usually  coated  with  a  glutinous  mucus,  which  it  is  necessary 
to  remove  in  order  to  gain  a  true  conception  of  the  nature  of 
the  tissues. 

"  Although  the  inequality  of  the  grayish  or  brownish-red  sur- 
face is  at  once  remarked,  it  is  not  until  after  hardening  by  pro- 
longed immersion  in  alcohol,  or  chromic  acid,  that,  having  ex- 
amined in  all  their  details  the  peculiarities  of  the  exterior  forms, 
we  can  appreciate  with  exactness  the  recent  condition. 

"  By  means  of  these  preparations  we  can  distinguish  the  defi- 
nite limit  which  sej)arates  the  extremity  of  the  roof  of  the  nasal 
cavity  from  the  vault  of  the  pharynx  to  which  it  is  united. 
Most  frequently  this  line  of  separation  is  a  distinct  notch  or  fur- 
row, behind  which  the  substance  of  the  pharyngeal  vault  inclines 
downwards,  passing  the  roof  of  the  nasal  cavity  to  a  variable 
distance,  the  maximum  being  4:^  millimetres ;  a  sort  of  ramj)art 
thus  forming  a  separating  line  between  these  two  neighboring 
cavities. 

"  The  adenoid  substance  of  the  nasal  portion  of  the  pharjmx 
extends  with  a  uniform  aspect  to  the  middle  of  the  border  o£ 
the  great  occipital  foramen ;  it  descends  even  as  far  as  the  re- 
gion of  the  anterior  arc  of  the  atlas,  where  it  terminates,  some- 
times in  the  form  of  an  uneven  irregular  line,  forming  more  or 
less  of  a  prominence  upon  the  adjacent  structures,  sometimes. 
resolving  into  isolated  follicles,  and  becoming  insensibly  merged 
into  these  structures. 

"  On  the  sides,  the  adenoid  substance  extends  towards  th& 
orifice  of  the  Eustachian  tubes,  and  forms  with  the  posterior 
reflexion  of  its  circumference  a  fissure  of  greater  or  less  depth, 
recessus,  seu  lacuna  jpliaryngis,  or  fossa  of  liosenmiiller 
(Fig.  37 — 6),  which  joins,  above,  the  sort  of  rampart  of  which 
we  have  spoken,  and  is  continuous  below  with  the  furrow  or 
notch  formed  by  the  junction  of  the  posterior  and.  lateral  walls 
of  the  pharynx. 

"  This  recessus  pharyngis,  arising  from  the  projection  of  the 

Eustachian  tube  in  the  cavity  of  the  pharynx  (the  maximum  of 

its  depth,  which  diminishes  successively  above  as  below,   not 

exceeding  a  depth  of  1^  centimetre),  corresponds  to  the  lengthi 

12 


178 


SPECIAL   AFFECTIONS    OF   THE    PHARYNX. 


of  that  portion  of  the  cartilage  of  the  tube  covered  by  the  pharyn- 
Teal  mucous  membrane.  Frequently  this  recess  is  not  unin- 
terrupted in  its  entire  length, 
but  is  divided  by  bridges 
formed  of  mucous  membrane, 
and  uniting  the  posterior  wall 
of  the  nasal  portion  of  the 
pharynx  to  the  neighboring 
reflexion  of  the  pharyngeal 
orifice  of  the  Eustachian  tube 
which  faces  it.  The  more  nu- 
merous these  junctions,  the 
more  does  the  adenoid  tissue 
cover  this  portion  of  the  cir- 
cumference of  the  tube,  the 
polish  of  which  disappears  ; 
there  is  no  longer  a  distinct 
limit  to  the  adjacent  tissues, 
so  that  the  recessus  pharyngis 
may  be  entirely  wanting. 

"The  free  surface  of  the 
nasal  portion  of  the  pharynx, 
extending  between  the  orifices 


Adenoid  Tissue  op  Vault  op  Phaetnx,  from 
Luschka. 

Fig.  37.  Posterior  wall  of  the  superior  vor- 
tion  of  the  human  pharynx,  seen  from  before 
backwards,  upon  a  transversal  section.  Natural 
size,  after  Luschka. — 1-1.  Pterygoid  process. 
— 2.  Section  of  the  vomer. — 3-3.  Posterior 
portion  of  the  vault  of  the  nasal  fossa. — 4-4. 
Pharyngeal  orifice  of  the  Eustachian  tube. — 5. 
Orifice  of  the  pharyngeal  iwuch  (Bursa  pharj'n- 
gea.) — 6-6.  Recessus pharyngeus  (fossa  of  Rosen- 
miiller. ) — 7.  Median  folds  formed  by  the  adenoid 
substance  of  the  nasal  iiortioti  of  the  pharynx. 


of  the  two  Eustachian  tubes 
and  descending  from  the  ex- 
tremity of  the  nasal  cavities  to 
the  anterior  border  of  the  great  occipital  foramen,  does  not  al- 
ways present  the  same  aspect,  even  in  normal  conditions.  In  a 
very  few  instances  we  see  the  surface  delicately  crossed  by  deep 
clefts  longitudinally  directed,  forming  leaves  separated  by  these 
clefts,  or  projecting  ridges  which  reunite  in  part  by  the  formation 
of  a  sort  of  network.  Most  frequently  we  observe  a  mamelona- 
ted  surface  interrupted  by  short  fissures,  often  irregular,  and 
varying  in  number  and  position.  Whether  we  have  the  one 
type  or  the  other,  the  fi-ee  surfaces,  as  well  as  those  bordering 
upon  the  clefts,  are  studded  with  innumerable  white  nodosities, 
hardly  of  the  size  of  a  poppy-seed.  These  are  the  follicles  of 
the  adenoid  substance,  and  present  a  fine  glandulous  appear- 


GLANDULAR  IIYPEETROPHY  AT  VAULT  OF  PHARYNX.    179 

ance.  We  observe,  in  addition,  a  great  number  of  round  pores, 
formed  in  part  by  the  isolated  follicles  of  the  depressed  mucous 
membrane  and  in  part,  and  principally,  by  the  mouths  of  so 
many  acinous  glands. 

"  Almost  always  a  much  larger  orifice  is  noticed  in  the  region 
of  the  adenoid  tissue,  and  it  is  situated  at  the  inferior  limit  of 
its  median  line  (Fig.  37 — 5).  It  is  sometimes  circular,  and  its 
diameter  is  that  of  a  pin-head ;  sometimes  it  appears  larger, 
and  is  not  often  defined,  except  above,  by  a  more  or  less  distinct 
border.  This  opening  represents  the  entrance  of  an  appendix 
of  the  vault  of  the  pharynx,  in  the  form  of  a  pouch,  oblong, 
having  a  maximum  length  of  1^  centimetre,  and  6  millimetres 
in  breadth,  which,  joined  by  a  cushion  of  loose  cellular  tissue 
to  the  adenoid  substance,  rises  behind  it  towards  the  body  of 
the  occipital  bone,  where  it  terminates  by  a  narrow  extremity, 
sometimes  pointed,  penetrating  the  external  fibrous  element 
of  this  bone.  At  its  posterior  portion  this  pouch  is  ordinarily 
enveloped  by  acinous  glands. 

"  Sometimes  its  sides  are  surrounded  by  a  muscle,  arising  by 
a  flat  tendon  of  fibrous  tissue  from  the  inferior  surface  of  the 
basilar  apophysis.  This  muscle,  which  exists  only  exceptionally, 
may  be  considered  as  the  superior  bundle  of  the  cejDhalo-pharyn- 
geal  muscle ;  a  bundle  enveloping  in  the  form  of  a  knot  the 
lateral  portions  of  the  vault  of  the  pharynx.  The  lateral  extrem- 
ity of  the  cephalo-pharyngeal  muscle  arises  within  the  Eustachian 
tube,  towards  the  root  of  the  internal  plate  of  the  pterygoid 
apophysis. 

"  It  was  in  certain  mammif  ers  (horse  ?  Tr.)  provided  with  this 
appendix  of  the  vault  of  the  pharynx,  that  F.  J.  C.  Mayer  ob- 
served it  for  the  fij'st  time ;  and  he  gave  it  the  name  of  the 
pharyngeal  hursa. 

"  We  often  notice  on  the  external  face  of  the  body  of  the  oc- 
cipital bone,  in  front  of  the  pharyngeal  tubercle,  a  little  fossa 
corresponding  to  the  superior  extremity  of  the  appendix ;  and 
vsrhich,  upon  a  cranium  of  a  Bushwoman  which  is  before  me,  has 
a  depth  of  several  millimetres,  and  is  prolonged  anteriorly  under 
the  form  of  a  gutter.  T.  H.  Tourtal  has  also  observed,  upon 
the   craniums  of  a  Bushman  and   a   Caffray,  the   exceptional 


180  SPECIAL    AFFECTIONS    OF   THE    PHAEYISTX. 

development  of  this  fossette,  the  imprint  of  the  pharyngeal 
bursa. 

"  The  wall  of  the  pharyngeal  bursa  (Fig.  38),  formed  especially 
of  adenoid  substance,  has  a  thickness  varying  fi-om  |-  to  1^  milli- 
metre; its  mucous  membrane  is  not  generally  uniform,  but  pro- 
vided with  irregular  projecting  tubercles,  and  folded  in  longi- 
tudinal plaits.  Sometimes  the  contracted  superior  extremities 
become  strangulated,  and  transformed  into  a  cyst.  In  one  case 
that  I  observed,  this  strangulation  was  repeated  several  times, 
giving  a  knotted  aspect  to  the  pharyngeal  bursa.  This  modiii- 
cation  recalls  the  irregularly  interrupted  obliteration  of  the 
vaginal  tunic  of  the  peritonaeum,  producing  cystic  hydrocele  of 
the  spermatic  cord ;  it  also  recalls  the  swellings  of  the  median 
ligament  of  the  bladder  remaining  attached  to  the  urachus,  and 
of  which  a  portion  is  normally  free  for  a  certain  length.  It  is 
not  doubtful  that  this  appendix  is  but  a  foetal  relic  without 
functional  importance,  a  condition  also  indicated  by  the  pos- 
sibility of  its  absence,  and  by  the  variability  of  its  dimensions. 
It  is  coniirmative  of  the  hypothesis  of  Eathke,  that  the  glandular 
lobe  of  the  pituitary  body  is  especially  produced  through  a 
strangulation  of  the  mucous  membrane  of  the  pharynx ;  and  we 
may  the  less  rest  our  hypothesis  on  the  genetic  relation  of  the 
pharyngeal  bursa  to  the  pituitary  body,  inasmuch  as  I  have  de- 
monstrated in  the  foetus  the  existence  of  this  excavation,  which 
is  developed  by  growth  at  a  later  date.^  Thus  we  negative 
absolutely  the  question  propounded  by  Tourtal : — as  to  whether 
there  is  not  some  relation  between  tlie  pharyngeal  bursa  and  the 
development  of  the  cavity  of  the  sphenoid  bone. 

"The  opinions  of  anatomists  upon  the  structure  of  the  toalls 
of  the  vault  of  the ])haTynx  are  divided.  Some  admit  the  pre- 
sence of  a  conglobate  glandular  substance,  and  others  deny  it. 
While  Kolliker  finds,  in  accordance  with  Lacauchie,  a  glandular 
mass  having  the  structure  of  the  tonsils,  at  the  place  where  the 
pharynx  attaches  itself  to  the  base  of  the  cranium,  Henle  affirms 
tliat  he  has  but  rarely  found  some  small  flattened  depressions  at 


'  The  Pituitary  Body  and  the  Coccygeal  Gland.      Luschka.      Berlin,  i860, 
4to,  pi.  i.  and  ii. 


GLAl^DULAE  HYPERTROPHY  AT  VAULT  OF  PHARYNX.      181 


the  superior  portion  of  the  pharynx  of  an  aspect  analogous  to 
that  which  the  follicles  of  the  intestine  present  when  they  have 
been  destroyed.  But  this  ob- 
server was  unable  to  find  a  con- 
globated glandular  substance, 
either  in  the  walls  of  these  de- 
j)ressions,  or  about  the  excava- 
tions proper  to  the  vault  of  the 
pharynx. 

"In  view  of  this  controversy 
between  celebrated  anatomists 
upon  so  important  a  point,  and 
in  consideration  of  the  variable 
forms  under  which  this  substance 
is  produced  in  the  various  re- 
gions of  the  body,  I  deemed  it 
my  duty  to  extend  my  jjersonal 
researches  over  a  great  number 
of  cadavers  procured  fi'om  in- 
dividuals of  different  ages.  I  ar- 
rived, in  every  case,  to  the  one  re- 
sult :  in  complete  opposition  to  the 
opinion  of  Henle.  I  invariably 
found  a  large  conglobated  glandular  mass,  attaining  a  maximum 
thickness  of  8  millimetres,  and  extending  between  the  orifices 
of  the  Eustachian  tubes,  with  a  medium  length  of  3  centimetres, 
departing  from  the  posterior  extremity  of  the  roof  of  the  nasal 
cavity.  This  glandular  substance,  soft  and  spongy,  is  so  inti- 
mately connected  with  the  solid  cartilaginous  tissue  which  unites 
the  pharynx  to  the  base  of  the  cranium,  that  it  is  almost  im- 
possible to  separate  them  distinctly.  It  is  not  possible  to  isolate 
the  mucous  membrane,  the  tissue  of  which  loses  itself  without 
interruption  in  the  connective  reticular  substance ;  and  it  is,  al- 
most to  the  very  surface,  so  infiltrated  with  cellules  similar  to 
the  lymphatic  corpuscles,  that  it  seems  to  be  nothing  else  than 
a  thin  limiting  structure  surmounted  with  flat  papules  hardly 
perceptible,  and  covered  with  lengthened  vibratile  cellules. 

"  The  greater  portion  of  the  glandular  tissue  is  formed  either  of 


Pharyngeal  Bursa  (from  Luschka). 

Figure  38. — ^Antero-postero  section  of  the 
vault  of  the  pharynx.  Natural  size,  after 
Luschka.  1.  Section  of  the  basilar  process  of 
the  occipital  bone.  2.  Body  of  the  sphenoid. 
3.  Pituitary  gland.  4.  Adenoid  substance  of 
the  vault  of  the  pharynx,  behind  which  is 
seen,  5.  The  pharyngeal  bursa. 

N.B. — The  line  of  reference  from  5  is  car- 
ried beyond  the  bursa  in  the  cut. 


182  SPECIAL    AFFECTIOjS^S    of   the   PHAEYJSrX. 

leaves  separated  by  deej)  clefts,  or  of  round  pockets,  more  or  less 
distinct,  with  walls  of  the  medium  thickness  of  1  millimetre, 
embracing  cavities  lined  with  vibratile  epithelium,  in  which  the 
mucous  membrane  prolongs  itself  through  relatively  straight 
openings.  These  round  pockets,  produced  by  the  penetration  of 
the  mucous  membrane,  and  attaining  to  the  size  of  a  pea,  are  in 
part  separated  by  thin  layers  of  the  ordinary  fibrous  connective 
tissue,  which  makes  them  in  some  sort  isolable ;  in  part,  especially 
towards  the  surface,  they  become  lost  in  one  another  without 
interruption,  so  that  the  conglobated  glandular  substance  of  their 
walls  appears  continuous,  and  penetrated  by  an  irregular  system 
of  cavities,  terminating  by  numerous  openings  in  the  fi^ee  sur- 
face of  the  mucous  membrane.  Under  both  conditions  we  have 
always  a  system  of  thin  cordons,  united  to  each  other  in  the 
form  of  a  network,  in  the  meshes  of  which  are  found  elements 
similar  to  the  lymphatic  corpuscles,  and  in  such  abundance  that 
they  conceal  everything  else. 

"  In  this  substance,  constituted  as  it  may  be,  as  the  analogous 
substance  of  the  lymphatic  apparatus  called  after  His  'ade- 
noid tissue,'  or  with  Henle, '  conglobated  glandular  substance,' 
are  found  small  nodosities  of  the  same  nature  as  the  solitary 
follicles  of  the  intestine,  and  identical  with  them  under  all 
relations.  These  nodosities,  of  variable  quantity,  but  never 
absent,  are  softer  than  the  rest  of  the  substance,  and  are  dis- 
tinguished in  the  recent  state  by  a  whitish  color.  Their  size  is 
variable ;  normally  they  do  not  surpass  that  of  a  poppy-seed  ; 
but  under  an  abnormal  influence,  the  increase  of  size  may  be 
very  great.  They  show  themselves  intact  at  the  surface  of  the 
vault  of  the  pharynx,  and  if  they  are  sufficiently  numerous, 
they  give  it  a  granular  appearance.  In  a  section  of  a  hard- 
ened preparation,  showing  most  clearly  the  separation  of  the 
isolated  pockets,  the  disposition  of  these  nodosities  may  be 
readily  seen  in  the  walls  of  these  pockets,  as  well  as  the  promi- 
nence of  a  certain  number  towards  the  cavities  of  these  last, 
where  they  advance  more  or  less  deeply,  under  the  form  of 
rounded  eminences. 

"  Like  the  solitary  glands  of  the  intestine,  these  nodosities  are 
not  distinctly  separated  by  the  eye  from  the  surrounding  tissues. 


GLANDULAR  HYPERTROPHY  AT  VAULT  OF  PHARYNX.      183 

In  fact  they  do  not  appear  in  their  extent,  except  bound  to  the 
ceUular  network  by  some  thickenings  of  this  tissue.  But  their 
fundamental  tissue  is  the  same  as  that  of  the  neighboring 
structures,  a  network  continuous  with  the  ambient  portions,  and 
which  becomes  more  delicate  as  it  embraces  the  larger  meshes, 
and  approaches  more  to  the  centre.  Towards  the  middle  the 
network  is  most  fi-equently  lost  entirely,  in  such  fashion  as  to 
produce  a  sort  of  common  central  space. 

"  In  general,  the  little  vessels  sustained  by  the  network  do  not 
extend,  as  it  were,  to  the  woof,  but  become  inflected  towards 
the  centre,  and  are  most  frequently  sinuous.  It  sometimes 
occurs,  howcA'er,  that  the  capillaries,  united  among  themselves 
in  the  form  of  a  reticulum,  penetrate  the  space  left  free  by  the 
network.  This  network  consists  of  colonnettes  of  greater  or 
lesser  size,  partly  in  continuation  with  the  external  tunic  of  the 
vessels,  the  relations  of  which  cannot  be  distinguished  except 
in  preparations  hardened  in  absolute  alcohol ;  and  a  certain 
number  of  these  colonnettes  unite  to  form  a  knot,  sometimes 
dilated.  Though  recognizing  that  the  filaments  of  cellular 
tissue  are  the  principal  constituent  elements  of  these  nodosities, 
it  is  also  necessary  to  remark  that  there  enter  into  their  forma- 
tion cellular  elements,  the  prolongations  of  which  penetrate 
into  the  woof  of  the  reticulum.  I  am  not  at  present  prepared 
to  pronounce  upon  the  primitive  disposition  of  the  reticulum  of 
the  adenoid  substance  of  the  pharynx,  and  to  say  whether  it 
represents,  or  to  what  extent  it  represents,  a  pure  cellular  net- 
work, such  as  it  would  seem  to  be  with  the  IpnjDhatic  glands, 
according  to  the  recent  embryological  researches  of  E.  Sertoli 
upon  the  development  of  these  organs. 

"  The  reticulum  of  the  follicles  in  the  walls  of  the  glandular 
pouches  of  the  pharynx  is  infiltrated  with  elements  which,  by 
their  size,  their  form,  their  reaction,  resemble  the  lymph  corpus- 
cles. Their  exaggerated  increase  may,  if  they  coincide  with 
the  disappearance  of  the  fibrous  support,  give  rise  to  the  pro- 
duction of  pouches  of  a  greater  extent,  of  which  the  contents, 
sometimes  presenting  |;he  consistence  and  color  of  a  caseous 
substance,  at  times  evince  a  colloid  degeneration.  The  disap- 
pearance of  the  conglobated  glandular  substance  is  frequently 


184  SPECIAL    AFFECTIONS    OF   THE    PHARYISTX. 

connected  with  erosion  of  the  mucous  membrane,  which  results 
in  the  formation  of  cavities  which  may  acquire  a  variable  size 
and  depth.  It  is  not  solely  to  this  metamorphosis,  and  to  others 
analogous,  that  the  adenoid  tissue  of  the  nasal  portion  of  the 
pharynx  owes  an  important  practical  interest;  but  also  because 
by  its  excessive  development  it  may  give  rise  to  the  i3roduction 
of  a  peculiar  species  of  j)haryngeal  polyp."  ' 

A  case  has  recently  come  under  the  observation  of  the  author, 
while  engaged  in  the  preparation  of  this  volume,  which  has 
enabled  him  to  study  the  external  anatomy  of  this  region  at 
leisure  in  the  living  subject.  A  young  girl,  aged  fifteen  years, 
perfectly  healthy  in  every  respect,  was  sent  to  the  author  for  the 
purpose  of  undergoing  a  periosteo-plastic  operation  for  the  clo- 
sure of  a  large  congenital  cleft  in  the  hard  and  soft  palate.  The 
cleft  permitted  a  direct  view  of  the  vault  of  the  pharynx,  and  the 
adenoid  or  follicular  tissue  occupying  this  situation.  A  careful 
drawing  was  made  by  an  artist,  and  kindly  corrected  after- 
wards, with  the  subject  before  him,  by  Dr.  Packard,  of  this 
city,  who  adds  skilful  knowledge  of  drawing  to  his  numerous 
professional  and  social  accomplishments.  The  engraving  follow- 
ing gives  a  very  accurate  idea  of  the  appearance  of  the  parts  under 
consideration.  At  the  upper  part  of  the  cleft,  the  head  of  the 
patient  being  thrown  well  backwards,  we  distinguish  the  incom- 
plete vomer,  and,  at  each  side  of  it,  the  lower  and  middle 
turbinated  bones.  The  broad  bright  spot  indicates  the  angle 
formed  between  the  upper  part  of  the  vomer  and  the  roof  of 
the  pharynx,  where  we  observe  the  structure  in  question.  To 
cither  side,  at  the  edges  of  the  cleft,  the  trumpet-shaped  ex- 
tremity of  the  Eustachian  tube  is  clearly  seen,  with  its  pharyn- 
geal orifice.  The  anatomical  relations  of  the  healthy  parts  are 
perfect.  Below  the  mass  of  glandular  tissue  is  seen  the  out- 
line of  the  upper  constrictor  muscle  of  the  pharynx,  the  action 
of  which  in  contraction  was  well  seen  by  titillating  the  parts 
with   a  probe  during  the  examination.     The  wavy  portion  on 


'  Das  adenoide  Gewebe  der  Pars  Nasalis  des  menschlichen  Schlundkopfes. 
Hubert  von  Luschka.  {ArcJiio  far  mikroskopische  Aiiatomie,  18(58,  8vo  Vol. 
rv.  pi.  1.) 


GLANDULAE  HYPERTROPHY  AT  VAULT  OF  PHARYJSTX.      185 


the  left  side  of  the  phaiynx,  seen  less  distinctly  upon  the  right, 
is  the  lower  portion  of  the  salpingo-pharyngens  muscle,  which, 
arising  from  the  posterior  and  cartilaginous  portion  of  the 
tube,  descends  to  the  sides  of  the  pharynx.     The  action  of  all 


ri-'.  n9. 


View  of  Glandular  Tissue  at  Vault  of  Pharynx,  in  a  Case  of  CleJt  Palate. 

the  pharyngeal  and  palatine  muscles,  including  the  posterior 
portion  of  the  levator  veli,  the  reflection  of  which  forms  the 
anterior  and  muscular  portion  of  the  Eustachian  orifice,  was 
also  beautifully  exhibited  in  this  interesting  case. 

In  the  next  drawing  the  cheek  of  the  patient  has  been  drawn 
to  one  side,  so  as  to  permit  a  further  view  into  the  cavity  of  the 
pharynx  on  the  opposite  side,  revealing  the  entire  pharyngeal 
extremity  of  the  Eustachian  tube,  and  the  whole  of  its  orifice. 


186 


SPECIAL    AFFECTIONS    OF   THE   PHARYNX. 


This  drawing  was  also  touched  up  by  Dr.  Packard  before  being 
finally  submitted  to  the  engraver. 


Pig.  40, 


View  ot  Left  Eustachian  Orifice  in  a  Case  of  Cieft  of  Hard  Palate. 

This  case  is  the  one  operated  upon  by  sjDlitting  the  edges  of 
the  cleft  instead  of  paring  them,  already  referred  to  under  the 
head  of  cleft  palate. 

It  will  be  seen  in  the  drawings,  that  the  tissue  in  this  instance 
is  arranged  symmetrically  on  either  side,  in  the  form  of  five  or 
six  elongated  club-shaped  lobes  on  each  side,  with  the  bases 
upwards  and  outwards,  and  the  narrower  extensions  running 
downwards,  and  inwards  towards  each  other,  the  clefts  or  lines 
of  separation  between  these  lobes  being  distinctly  marked  and 
running  together  to  form  a  median  cleft  of  greater  depth  and 


GLAIfDULAE  HYPEETEOPHY  AT  VAULT  OF  PHAEY]^X.      187 

width.  The  entire  mass  was  of  a  brilliant  red  color,  similar  to 
that  of  yascular  nincous  membrane.  The  dividing  spaces  or 
clefts  were  occupied  bj  a  slightly  opalescent  fluid,  secreted 
from  the  glands;  and  where  the  different  streams  joined  in  the 
central  cleft  and  ran  down  the  posterior  portion  of  the  struc- 
ture, the  opalescence  was  marked  and  milky  in  appearance. 
On  removing  this  secretion  with  a  sponge,  the  adjacent  surfaces 
of  the  lobes  were  seen  to  have  a  slightly  wrinkled  aspect, 
as  if  minutely  furrowed,  and  the  bottoms  of  the  clefts  were 
of  the  same  color  as  the  lobes.  The  secretion  reaccumulated 
under  the  eye  with  great  rapidity.  The  appearance  bears  a 
striking  resemblance  to  that  described  by  Luschka  from  ob- 
servations upon  the  dead  subject;  but  there  was  no  vestige  to 
be  seen,  even  with  the  aid  of  a  magnifying  lens,  of  any  central 
depression  or  pit  marking  the  orifice  of  the  phai-yngeal  bursa. 
There  is  not  the  slightest  doubt  that  we  have  in  this  case  a 
marked  exemplification,  in  situ,  of  tliis  adenoid  or  glandular 
tissue  of  the  nasal  portion  of  the  pharynx ;  but  evidently  in  a 
slight  state  of  hypertrophy  from  the  local  irritation  to  which  it 
has  been  subjected,  during  the  whole  life  of  the  patient,  on 
account  of  its  exposed  situation.  It  will  be  an  interesting- 
source  of  supplemental  observation  to  watch,  with  the  rhino- 
scope,  for  the  retrocession  of  this  structure  to  its  normal  dimen- 
sions, following  the  closure  of  the  cleft  in  the  palate. 

Although  the  presence  of  this  structure, — this  "  pharyngeal 
tonsil "  as  it  has  been  not  inaptly  termed, — has  been  discerned 
frequently  upon  rhinoscopic  examination  of  the  healthy  sub- 
ject, it  cannot  by  any  means  be  distinguished  in  all  cases  ;  but 
experience  teaches  me  that  if  always  hunted  for  it  will  be 
fi-equently  recognized,  even  though  there  may  be  at  first  only 
doubtful  evidence  of  its  presence.  It  is  not  always  recogniz- 
able in  cases  of  cleft-palate.  In  one  or  two  cases  of  this  kind, 
in  which  I  looked  for  it  ao;ain  and  again  by  refiected  lio-ht,  I 
could  not  convince  myself  of  any  manifestation  of  its  appear- 
ance. I  have  frequently  observed  it,  however,  in  the  rhinoscopic 
image,  and  have  distinctly  recognized,  in  a  few  instances,  the 
central  depression  of  the  pharyngeal  bursa. 

As  a  usual  thing  no  distinct  line  of  demarcation  between  the 


188  SPECIAL   AFFECTIOJ^TS    OE    THE    PHARYJSTX, 

nasal  portion  of  the  pharjmx  and  the  vault  of  the  pharynx  can 
be  recognized,  the  parts  merging  into  each  other  by  a  smooth 
"uninterrupted  surface ;  but  sometimes  a  deep  furrow  is  dis- 
tinctly seen  in  this  situation,  separating  these  two  portions  of 
the  pharyngeal  cavity.  In  one  case  of  tliis  kind,  recently 
under  the  author's  treatment,  not  only  was  this  furrow  well 
marked,  but  it  was  crossed  on  either  side  of  the  middle  line, 
just  above  the  roof  of  the  nasal  openings,  by  several  delicate 
bands  of  tissue,  similar  in  appearance  to  those  bands  so  often 
seen  crossing  the  fossa  of  Hosenmiiller — a  condition  also  existing 
in  the  case  referred  to.  This  patient  applied  for  relief  from 
an  annoyance  of  many  years'  duration,  the  principal  symptom 
of  which  was  a  constant  dropping  of  mucus  from  the  posterior 
nasal  region  into  the  throat ;  sometimes  entering  the  larynx  and 
inducing  cough.  A  rhinoscopic  examination  revealed  the  con- 
dition of  parts  just  described,  as  well  as  the  existence  of  a  fim- 
briated elongation  of  some  of  the  follicles  composing  the  glan- 
dular mass  at  the  vault  of  the  j^harynx.  The  parts  were  normal 
in  color,  and  the  disease  confined  to  this  locality.  The  secretion 
from  these  glands  accumulated  on  the  little  bridges  formed  by 
the  bands  of  adhesion,  and  when  collected  into  drops  fell  fi-om 
them  into  the  throat. 

The  treatment  consisted  in  rupturing  these  adliesions  by 
means  of  a  blunt,  catheter-like  metallic  probe  passed  behind 
the  palate,  followed  by  the  projection  upon  the  parts  of  a  tole- 
rably strong  solution  of  carbolic  acid  in  glycerine  and  water. 

Of  the  form  of  affection  under  consideration,  with  the  exist- 
ence of  which  I  have  been  familiar  for  four  or  five  years  only, 
I  have  seen  some  thirty  cases  or  more,  principally  in  adult 
males.  In  some  instances  these  vegetations  exist  in  but  a  slight 
amount ;  but  I  have  frequently  seen  them  studding  the  entire 
vault  of  the  pharynx  fi'om  side  to  side,  hanging  over  the  upper 
margins  of  the  posterior  nasal  orifices,  and  completely  hiding 
the  view  of  the  pharyngeal  orifice  of  the  Eustachian  tube ;  and 
as  has  been  the  case  with  Yoltolini  and  others,  I  have  discerned 
them  unexpectedly  in  examinations  of  this  region  in  patients 
suffering  from  chronic  catarrh  of  the  middle  ear.  In  some  in- 
stances they  are  said  to  be  so  numerous  as  to  fill  up  the  entire 


GLANDULAR  HYPERTROPHY  AT  VAULT  OF  PHARYNX.      189 

upper  cavity  of  the  pharynx,  and  to  give  to  the  finger,  when 
passed  behind  the  vehim,  the  sensation  of  bunclies  of  earth- 
worms. I  have  never  met  witli  them  in  anything  like  this  pro- 
fusion. Dr.  William  Meyer,  of  Copenhagen,  has  described  this 
affection  in  an  elaborate  article  entitled  "  Adenoid  Vegetations 
in  the  ISTaso-pharyngeal  Cavity ; "  ^  his  attention  ha^^ng  been 
first  called  to  it  as  the  cause  of  the  defect  in  speech,  mentioned 
in  the  early  part  of  this  article  as  one  of  the  symptoms  of  the 
affection.  He  states  that  he  has  met  with  102  cases  of  the 
disease  in  his  private  practice  within  a  period  of  eighteen 
months  after  his  attention  had  been  directed  to  the  disease  in 
his  first  case — a  remarkable  number,  certainly ;  for  before  the 
perusal  of  his  article  I  was  inclined  to  the  belief  that  the  affec- 
tion was  an  infrequent  one,  judging  from  my  own  experience, 
that  of  friends  with  whom  I  had  conversed  on  the  subject,  and 
the  small  number  of  published  cases  on  record.  Dr.  Meyer 
examined  2,000  children  in  the  public  schools  for  the  poor  in 
Copenhagen,  and  discovered  20  of  them  with  the  peculiar 
defect  of  enunciation  which  he  calls  '■'' dead''''  jpronimciation, 
in  all  of  whom  he  met  with  the  existence  of  these  adenoid  vege- 
tations. Dr.  Meyer  states  that  he  has  met  them  almost  com- 
pletely filling  up  the  naso-pharyngeal  cavity  behind  the  velum, 
and  gi^'iug  to  his  finger  a  sensation  much  like  tliat  of  a  bunch 
of  earth-worms.  In  fact,  he  depends  upon  his  finger  as  a  means 
of  diagnosis  much  more  than  he  does  upon  the  rhinoscope; 
for  he  states  that  they  are  sometimes  so  extensive  as  to  pre- 
clude the  use  of  this  instrument,  and  that  in  some  instances 
the  velum  is  so  thickened  on  its  posterior  surface  that  it  en- 
croaches too  much  upon  the  cavity  to  admit  the  mirror,  even 
when  the  space  itself  is  not  so  fully  occupied  by  the  vegeta- 
tions. 

These  glandular  enlargements  are  sometimes  flatfish  cushions, 
similar  to  the  prominences  seen  in  some  cases  of  follicular 
disease  of  the  middle  and  lower  portion  of  the  pharynx.    Some- 


'  Hospitals  Tidende,  Nov.  4,  and  11,  1868.  Extensively  reviewed,  in 
Sehmidfs  Jahrb.,  141,  1869,  p.  335.  Communicated  in  English  in  Medico- 
CMrurgical  Transactions^  p.  191.     London,  1870.    Illustrated. 


190 


SPECIAL    AFFECTIOT^S    OF    THE    PHARYNX. 


Ehinoscopic  View  of    Grlandvilar 


times  they  are  cylindrical,  and  very  often  indeed  fimbriated,  hang- 
Fig.  41.  ing  down  like  irregular  tassellated  fringes. 
(Fig.  41.)  Sometimes  they  are  isolated,  at 
others  in  close  apposition.  They  are  usual- 
ly of  soft  consistence  and  bleed  very  freely 
on  contact  with  the  sponge,  or  even  when 
struck  with  a  stream  of  fluid  projected 
upon  them  from  the  syringe.  They 
usually  occupy  the  vault  of  the  pharynx, 
and  the  sides  of  the  cavity  overhanging 
.the     cartilaginous      projection     of      the 

Vegetations  at  Vault  of  Pharynx.  EuStaclliaU  tube,  and    the  f  OSSa  of    RoSCU- 

niiiller.  I  have  never  seen  them  occupy  the  nasal  septum^ 
and  Dr.  Meyer  states  that  he  has  never  seen  them  there 
in  his  extensive  exj^erience ;  but  he  states  that  in  some  cases  he 
has  traced  them  down  the  posterior  pillar  of  the  palate  to  the 
level  of  the  tonsil,  and  in  a  few  instances  on  the  upper  surface 
of  the  soft  palate,  and  he  also  mentions  that  he  sometimes  finds 
these  growths  hard  as  well  as  soft  in  texture.  All  that  the 
author  has  seen  have  been  of  soft  consistence.  The  color  of 
these  vegetations  is  of  a  deep  red  at  the  base,  shading  oif  to  a 
lighter  pink  or  to  a  yellowish  cast  at  the  apex.  They  have 
much  the  color  of  the  free  surface  of  the  tonsil.  Their  free 
surfaces  are  usually  smooth,  but  sometimes  exhibit  that  velvety 
appearance  that  is  often  seen  in  the  follicular  enlargements  of 
chronic  pharyngitis. 

Dr.  Meyer  has  carefully  examined  the  microscopic  appear- 
ances of  these  vegetations,  and  it  may  be  well  to  compare  his 
description  with  that  of  the  normal  tissue  as  already  gixen 
from  the  observations  of  Luschka.  Meyer  says,^  "  the  surface 
of  a  section  of  a  recent  specimen  is  generally  smooth,  and 
shows  no  laminae  or  divisions  in  the  tissue.  Frequently 
small  round  yellowish  spots  may  be  seen,  or  cup-like  depres- 
sions, varying  in  size  but  always  small.  The  juice  pressed  out 
of  the  section  is  mostly  inconsiderable ;  it  is  transparent,  and 
contains  innumerable  lymph  corpuscles.     In  fine  sjDecimens  of 


1  Med.- C Mr.  Trans.  1870,  p.  196. 


GLANDULAR  HYPERTROPHY  AT  VAULT  OF  PHARYNX.      191 

sections  hardened  in  alcohol  or  dilute  solutions  of  chromic  acid 
the  light-colored  spots  are  much  more  distinct.  The  spots 
themselves  are  sometimes  pierced  by  a  hole  varying  from  the 
size  of  the  point  of  a  pin  to  1 — 1-|-  mm.  in  diameter,  or  they 
are  absent  altogether,  whilst  holes  of  the  same  dimensions  as 
the  spots  take  their  place. 

"  In  preparations  gently  brushed  with  a  sable-hair  brush,  and 
then  tinged  with  carmine,  a  very  transparent  delicate  network  is 
seen,  the  meshes  of  which  either  contain  more  or  fewer  lymph- 
cells  or  are  entirely  empty  where  the  brush  has  swejot  these  out. 
In  other  growths,  especially  in  those  of  the  side- walls,  the  threads 
of  the  network  are  coarser  and  the  meshes  smaller ;  these 
growths  were  further  distinguished  by  the  appearance  of 
genuine  and  sometimes  rather  firm  areolar  tissue.  The  little 
perforations  above  mentioned  are  the  cavities  of  normal  or  en- 
larged follicles,  from  the  compact  capsule  of  which  the  net- 
work extends  more  or  less  into  the  cavity,  growing  more  deli- 
cate as  it  proceeds  inwards.  The  excretory  ducts  of  aciniform 
glands  are  also  seen  in  great  numbers,  being  easily  recognized 
by  their  beautiful  epithelial  lining.  Most  specimens  are  ex- 
tremely vascular,  containing  arteries,  capillaries,  and,  still  more, 
veins,  as  distinguishable  by  the  direction  and  character  of  their 
parietal  nuclei.  Some  growths  even,  especially  those  of  the 
posterior  wall,  seem  to  be  made  up  exclusively  of  blood-vessels, 
between  the  numerous  ramifications  of  which  a  scanty  areolar 
network  containing  lymph-cells  is  interspersed.  The  connection 
between  the  meshes  and  the  outer  areolar  coat  or  perivascular 
areolar  tissue  of  the  blood-vessels  can  often  be  easily  perceived. 
The  epithelium  covering  the  vegetations  is  sometimes  ciliated, 
showing  wonderfully  distinct  cilia,  and  sometimes  of  the  pave- 
ment form,  composed  of  very  large  cells.  In  some  specimens 
both  forms  are  met  with,  either  separated  from  each  other  by  a 
well-marked  line  or  by  some  transitory  epithelial  cell-forms. 
Thus  the  microscopical  characters  may,  in  a  certain  degree, 
point  out  the  spot  from  which  the  growth  had  sprung.  Some- 
times the  follicles  are  so  near  the  surface  that  only  a  very  deli- 
cate lining  membrane  exists  between  their  walls  and  the 
epithelium." 


192  SPECIAL    AFFECTIONS    OF    THE    PHAEYISTX. 

Treatment. — The  treatment  of  these  vegetations  consists  in 
destroying  tliem  bj  caustics,  and  in  removing  them  by  surgical 
operation.  The  cauterization  may  be  performed  with  the  solid 
nitrate  of  silver  conveyed  to  the  parts,  under  guidance  of 
rhinoscopy,  by  means  of  a  curved  probe,  which  has  been 
dipped  into  the  melted  caustic,  or  upon  one  of  the  caustic- 
holders  described  in  connection  with  the  discussion  of  instru- 
ments employed  in  cauterizing  the  larynx.  Astringent  pow- 
ders may  be  propelled  upon  the  parts  in  like  manner,  from 
the  insufflator  of  Rauchf  uss.  Astringent  solutions  may  be  in- 
jected upon  the  parts  by  the  posterior  nasal  syringe.  I  have 
employed,  in  this  way,  tannin,  carbolic  acid,  sulphate  of  zinc 
and  of  copper,  calomel,  and  weak  solutions  of  nitrate  of  silver. 
Strong  solutions  of  nitrate  of  silver  are  not  always  well  borne 
by  any  means,  and  often  produce  an  intense  amount  of 
suffering,  which  sometimes  continues  in  the  form  of  an  excru- 
ciating headache  for  a  day  and  more.  Sneezing  is  very  often 
produced  by  these  applications,  and  sometimes  continues  for  many 
minutes.  It  is  well  to  test  the  sensibilities  of  the  parts  by  weak 
applications,  resorting  to  stronger  ones  as  tolerance  is  established. 

Where  the  vegetations  are  large,  and  the  parts  can  be  educa- 
ted to  quietude  under  manipulation,  these  growths  can  sometimes 
be  seized  with  properly  curved  forceps  and  be  torn  off  or  crushed 
off  as  the  case  may  be.  Under  these  circumstances  there  is  usually 
more  or  less  hemorrhage,  but  I  have  not  encountered  it  to  any 
such  extent  as  to  excite  alarm  or  uneasiness.  Sometimes  I  have 
scraped  them  off  with  a  blunt  instrument  resembling  a  vesical 
sound.  After  an  operation  of  this  kind  I  have  usually  projected 
powdered  alum  upon  the  parts,  or  syringed  them  with  a  weak 
solution  of  carbolic  acid.  A  slio-ht  amount  of  hemorrhao-e  con- 
tinues,  usually,  for  some  hours,  tingiiig  the  mucus  and  saliva 
which  is  expectorated.  A  number  of  opei'ations  are  usually 
necessary  in  order  to  rid  the  pharynx  of  these  growths. 

Fig.  42  represents  a  case  recently  treated  by  the  author,  in 
which  the  mass  was  torn  off  by  short  laryngeal  forceps  and 
then  cauterized  thoroughly  with  nitrate  of  silver,  giving  com- 
plete relief  to  an  unpleasant  "  nasal  catarrh  "  which  had  existed 
for  ten  or  twelve  years. 


TUMORS    OF   THE    PHARYjSTX.  193 

Dr.   Meyer  describes  an  instrument,  of  which  he  gives  an 
illustration/  devised  by  him  for  scraping  off  the  larger  vegeta- 
tions.    It  consists   of   a  little  transverse  Fig-  42. 
oval  ring  with  one  sharp  edge,  and  at- 
tached to  a  straight  stem.     It  is  carried 
to   the   parts   through    the    nostril    and 
guided  in  its  operation  by  the  fore-finger 
passed  up  behind  the  palate.     The  stem 
of  the  instrument   is    composed   of   soft 
steel,  so  that  it  can  be  bent  to  one  side 
or   the   other   as    may   be    desirable    to 
facilitate  manipulation.    The  hemorrhage     ^^^°^°^vio  view  of  a  case  of 

\  ,  .  glandular  hypertrophy  at  vault  of 

in   this   operation    is    considerable,    and  pharynx,  i.  Enlarged  glandular 
most  of  it  flows  out  of  the  nostrils.    After  ^^r'   ""  ':°''"  ■  ''f  f-""  "'*'' 

yellow     spots,     simulating     con- 
the    operation,    the    parts    should    be    well  cretlons.     3.  Fossa  of  Rosenmul- 

washed  with  a  rose  syiwe,  or  with  the  le;-  This  case  sho.-s  also  oedema 

•J         O    7  of  the  membrane  of  the  septum 

nasal   douche,   and    they   may   then    be  narium. 
cauterized  should  this  seem  necessary. 

The  whole  history  of  operations  of  this  kind  is  too  recent  to 
permit  the  formation  of  an  opinion  as  to  the  repullulation  of 
the  growths.  The  general  impression,  however,  is  that  there  is 
no  disposition  to  return. 

TUMOKS    OF   THE   PHARYNX, 

Tumors  of  various  kinds,  benign  and  malignant,  are  liable  to 
be  formed  in  the  pharynx  as  in  other  situations.  They  are  usual- 
ly developed  in  the  sub-mucous  connective  tissue ;  but  sometimes 
take  their  origin  from  the  bones.  The  mucous  membrane  of  the 
pharynx  compresses  them  so  tightly  that  they  are  not  very  mov- 
able. They  appear  to  occur  much  more  fi-equently  ujDon  the 
lateral  walls  of  the  pharynx  than  jDosteriorly,  and  when  thus 
located  often  involve  the  palatine  arches. 

These  tumors  are  not  often  recognized  until  after  they  have 
attained  a  considerable  size,  interfering  with  deglutition  and 
respiration  if  low  down,  and  with  distinct  articulation  if  high  up. 
Inspection  of  the  parts,  with  the  aid  of  palpation,  suffices  for  the 

1  Med.-Chir.  Tram.  1870,  p.  312. 
13 


194  SPECIAL    AFFECTIOlSrS    OF    THE    PHAKYISTX. 

diagnosis.  They  may  extend  upwards  to  the  region  of  the  pos- 
terior nares  and  Eustachian  tubes,  or  downwards  to  the  root  of 
the  tongue,  the  epiglottis,  or  the  walls  of  the  larynx  and  oeso- 
phagus. When  occupying  the  lateral  wall  of  the  pharynx  they 
may  be  confounded  with  tumors  of  the  tonsils. 

The  treatment  of  these  tumors,  when  not  malignant,  consists  in 
their  extirpation ;  and  the  operation  may  present  but  little  diffi- 
culty, or  be  extremely  embarrassing,  in  accordance  with  the  situa- 
tion of  the  tumor,  the  nature  of  its  attachments,  and  its  proximity 
to  the  carotid  artery.  Indeed  in  some  cases  of  tumors  in  this 
situation,  it  has  been  found  expedient  to  ligate  the  carotid  artery 
as  a  preliminary  measure ;  and  in  others  its  ligation  has  become 
necessary  during  the  performance  of  the  operation,  or  subse- 
quent to  it.  In  simple  cases  all  that  is  necessary  is  to  expose 
the  growth  fi^eely  by  a  straight  or  crucial  incision,  as  the  case 
may  demand,  through  its  mucous  coverings,  and  to  complete  the 
extirpation,  as  far  as  may  be,  by  means  of  the  fingers,  aided 
with  the  handle  of  the  scalpel,  or  with  some  other  blunt  instru- 
ment. Where  it  has  been  required  to  cut  through  the  soft  palate, 
it  is  sometimes  necessary  to  unite  the  edges  of  this  structure  by 
means  of  the  ligature. 

Most  of  the  tumors  operated  on  in  this  region  have  been  of  a 
fibroid  character ;  and  in  some  instances  have  been  followed  by 
a  recurrence  of  similar  growth,  necessitating  further  operation. 
In  a  case  of  the  latter  kind,  recorded  by  Wagner,'  death  occur- 
red by  suffocation  during  a  second  operation,  performed  five 
months  after  the  first  one.  The  cause  of  death  was  found  to 
have  been  due  to  pressure  of  the  epiglottis  upon  the  laryngeal 
orifice,  by  a  portion  of  the  tumor  which  had  been  dragged  out 
in  the  operation. 

Osseous  tumors  are  occasionally  formed  in  the  pharyngeal  re- 
gion. A  specimen  of  a  smooth  oval  exostosis  growing  from 
the  pharyngeal  vertebrse  is  preserved  in  the  museum  of  Guy's 
Hospital.^     The  author  has  recently  seen  a  case  of  this  kind. 

A  specimen  of  enchondroma  which  projected  into  the  cranium, 


1  Deutsche  Klinik^  1861,  p.  61. 

2  St.  George's  Hospital  Reports.     Vol.  ii.  1867,  p.  152. 


PHAEYNGOCELE .  195 

the  orbits,  the  antra,  the  nasal,  zygomatic,  and  pterygo-maxillary 
fossse,  is  contained  in  the  mnseum  of  St.  George's  Hospital/ 

I  have  met  one  case  of  ordinary  papilloma  growing  from  the 
mucons  membrane  on  the  posterior  wall  of  the  pharynx. 

PHAHYNGOCELE. 

A  diverticulnm  or  sac  is  sometimes  formed  in  the  pharynx, 
and  still  more  rarely  in  the  oesophagus.  It  is  occasionally  con- 
genital, but  is  more  frequently  the  result  of  external  injury  sus- 
tained in  swallowing  foreign  substances.  Sometimes  it  is  pro- 
duced by  the  repeated  catching  of  food  in  the  excavation  of  an 
ulcer,  the  walls  of  which  become  eventually  converted  into  a  sac. 
In  other  cases  it  seems  to  have  been  formed  by  the  mere  habitual 
retention  of  food,  which  gradually  distends  the  tissues  and  forms 
the  sac  ;  these  cases  occurring  principally  in  the  persons  of  hys- 
terical females. 

The  symptoms  of  this  affection  are  those  of  some  mechanical 
impediment  to  effectual  deglutition,  accompanied  very  often 
with  the  regurgitation  of  food.  Wlien  the  sac  is  empty  its  ex- 
istence can  be  detected  by  exploration  with  the  sound ;  when 
filled  with  food  it  presents  the  appearances  of  a  tumor  in  this 
region,  and  can  often  be  felt  from  the  outside. 

The  size  of  the  tumor  varies.  In  the  famous  case  of  Ludwig 
Kiihne  of  Neustadt,"*  the  tumor  had  attained  the  size  of  a  man's 
fist,  producing  death  after  nine  years'  suffering,  among  other 
things,  from  rumination. 

The  thinness  of  the  muscular  walls  of  the  pharynx  in  this 
situation  is  supposed  to  favor  the  formation  of  these  sacs,  by  the 
protrusion  of  the  mucous  membrane. 

The  treatment  for  this  affection,  when  high  enough  up  to  be 
reached,  would  seem  to  consist  in  excision  of  the  sac.  It  has 
been  recommended  to  cauterize  the  interior  of  the  sac,  and  to 
feed  the  patient  by  means  of  the  stomach-tube,  so  as  to  prevent 
any  retention  of  food  in  the  sac. 

1  St.  George's  Hospital  Bepoi^ts.     Vol.  ii.  1867,  p.  153. 

2  Albers.  Path.  Anat.  1839,  p.  373. 


196  SPECIAL    AFFECTIONS    OF   THE    PHAEYIS-X. 


NASO-PHAETNGEAL    TUMORS. 

Naso-Pharyngeal  Polyps. — This  name  is  given  in  a  general 
manner  to  tumors  of  various  characters  which  make  their 
appearance  in  the  superior  or  nasal  portion  of  the  pharynx — 
that  is,  the  portion  above  the  position  of  the  palate.  In  many 
instances  these  tumors  have  no  more  connection  with  the  nasal 
organ  or  its  accessoi-ies  than  if  they  occurred  in  the  lower 
portion  of  the  pharynx.  Nor  is  every  growth  in  this  I'egion  by 
any  means  a  jjolyp.  Cancerous,  fibrous,  enchondromatous  and 
osseous  tumors  are  also  developed  in  this  locality. 

Inasmuch,  however,  as  custom  has  applied  the  term  naso- 
pharyngeal polyp  to  all  tumors  in  the  upper  part  of  the  pha- 
rynx, it  will  be  necessary  to  consider  them  under  the  same 
head. 

The  true  polyp  is  sometimes  fibrous  and  sometimes  glandu- 
lar, apparently  originating  in  an  obstructed  follicle,  which  has 
become  gradually  converted  into  a  sac  containing  the  accumu- 
lated products  of  secretion  in  a  more  or  less  altered  state.     The 
fibrous   polyp   is  usually  of   a  reddish  or  purplish  color,  and 
arises  from  the  upper  cervical  vertebrae  at  the  posterior  wall  of 
the  pharjmx,  or  from  the  base  of  the  skull,  usually  to  one  side  or 
the  other,  rarely,  if  ever,  in  the  median  line.^     It   may  also 
arise  from  the   cartilaginous  portion  of  the  Eustachian  tube. 
A  tumor  in  this  region  may  take  a  partial  origin  from  some 
portion  of  the  posterior  circumference  of  the  nares,  and  under 
these  circumstances  constitute  a  naso-pharyngeal  polyp  in  reality. 
These  tumors  are  usually  slow  in  growth,  and  exhibit  a  great 
tendency  to  extend  prolongations  into  the  sinuses  of  the  nose 
and   face,  and   the   cavity  of  the  mouth,  thereby  eventually 
producing    a    characteristic    deformity   of    the    countenance, 
sometimes   denoininated  fi'og-face,  which   augments  with  the 
increasing  growth  and  encroachment  of  the  poly]). 

These   tumors   appear  at  all  ages,  but   most   frequently  in 
middle   life  ;  but  they  have   been  seen  in  the  foetus.      They 

^  This  point  is  being  investigated  by  Prof.  H.  AH  en,  of  Philadelphia,  who 
first  drew  mj  attention  to  the  circumstance. 


nSTASO-PHAEYNGEAL    TUMOES.  197 

are  not  recognized,  as  a  rule,  in  tlieir  early  stages,  but  only 
when  the  patient  applies  for  relief  from  frequent  epistaxis, 
increasing  or  permanent  obstruction  in  nasal  respiration,  chi'onic 
discharge  from  the  nostrils,  or  those  sjanptoms  of  deficient  ar- 
ticulation, impaired  deglutition,  or  impeded  respiration,  which 
have  been  elsewhere  refei-red  to. 

Inspection  with  and  without  the  use  of  the  rhinoscope,  palpa- 
tion by  the  finger,  and  explorations  with  the  probe  through  the 
nostrils,  establish  the  diagnosis. 

The  removal  of  tumors  from  the  nasal  portion  of  the  pha- 
rynx is  a  matter  of  great  difficulty,  chiefly  on  account  of  the 
inaccessibility  of  their  points  of  attachment  to  operative  proce- 
dure through  the  mouth  and  through  the  nostrils,  but  also  on  ac- 
count of  the  amount  of  attendant  hemorrhage,  and  the  difficulty 
in  restraining  it.  It  is  good  practice  to  accustom  all  the  parts 
which  will  be  subjected  to  manipulation  to  a  preliminary 
contact  with  instruments,  with  the  finger  passed  behind  the 
palate,  and  so  on,  so  as  to  secure  a  better  tolerance  during  the 
operation. 

Where  the  tumors  have  been  favorably  situated,  they  have 
been  seized  by  curved  forceps  passed  behind  the  palate,  or 
through  the  nostrils,  and  forcibly  torn  from  their  beds.  This  is 
by  no  means  a  safe  operation,  although  it  has  often  bpen  success- 
ful. Cases  are  on  record  of  death  from  hemorrhao'e  durino- 
the  operation,  and  also  from  secondary  hemorrhage  after 
the  operation.  In  addition  to  this,  these  tumors  occasionally 
extend  into  the  cranium,  and  thus  endanger  cerebral  hemor- 
rhage and  other  complications  when  roughly  torn  away. 

A  case  of  this  kind  has  been  recently  reported  to  the 
Clinical  Society  of  London,  by  Mr.  Cooper  Forster.*  "  The  pa- 
tient was  nineteen  years  of  age,  and  had  a  large  growth,  filling 
up  the  left  nostril,  firm,  fieshy,  and  fibrous,  and  covered  with 
mucous  membrane.  The  right  nostril  was  not  much  interfered 
with ;  there  was  no  swelling  of  the  face  or  fulness  of  the  palate, 
nor  any  projection  in  the  throat.     Chloroform  was  given,  and  a 


1  Lancet^  May  20,   1871 ;    Medical  Times  and  Gazette^  May  37,  1871 ;  The 
Medical  Times,  August  15,  1871. 


198  SPECIAL   AFFECTIONS    OF    THE    PHARYNX. 

wire  snare  was  put  round  the  growth,  which  broke  off,  and  caused 
it  to  bleed  profusely.  Mr.  Forster  then  made  another  examina- 
tion, and,  having  passed  his  finger  up  the  nostril,  found  an  enor- 
mous growth  which  could  not  be  circumscribed,  but  large 
portions  of  which  he  tore  away  with  forceps.  Four  days 
after  the  operation,  the  patient  suddenly  became  unconscious. 
The  right  half  of  his  face  was  numb,  and,  though  he  rallied, 
he  was  never  able  to  speak  except  to  say  "  too-too."  The 
temperature  rose  to  102°  F.  He  had  three  convulsive  fits 
on  the  seventh  day,  and  became  totally  unconscious  ;  and  died 
twelve  days  after  the  operation.  The  post-mortem  examination 
showed  general  arachnitis,  and  sloughing  of  the  brain  about 
Broca's  convolution.  That  portion  of  the  growth  which  had 
not  been  removed  occupied  the  left  side  of  the  external  base 
of  the  skull,  and  filled  the  base  between  the  greater  and  lesser 
wings  of  the  sjDhenoid,  the  orbital  plate  of  the  frontal,  and 
the  cribriform  plate  of  the  ethmoid  bone.  It  had  extended 
from  the  nasal  fossa  by  way  of  the  sphenoidal  fissure  into  the 
back  of  the  orbit,  but  without  damaging  the  optic  nerve. 
The  cribriform  plate  of  the  ethmoid  was  broken ;  and  at  the 
back  part  there  was  a  small  opening  about  a  quarter  of  an  inch  in 
diameter,  and  a  fi-acture  extending  forward  from  the  opening. 
Microscopic  examination  showed  the  growth  to  consist  of 
small  fusiform  cells  and  stellate  connective  tissue." 

The  cutting  away  of  accessible  portions  by  curved  knives 
and  scissors,  used  through  mouth  or  nostril,  is  still  more  apt  to 
be  attended  by  severe  hemorrhage,  primary  or  secondary, 
though  not  likely  to  injure  the  cerebral  structures  in  the 
unfortunate  cases  in  which  they  are  involved. 

The  passage  of  a  ligature  around  the  base  of  the  tumor  by 
means  of  a  thread  passed  through  the  canule  of  Bellocq,  and 
the  subsequent  excision  of  the  growth,  after  securing  the 
ligature,  is  attended  with  less  risk ;  but  even  an  operation  of 
this  kind  has  been  followed  by  death. 

Another  operation,  which  has  been  extensively  practised, 
consists  in  ligating  the  tumor,  so  as  to  destroy  its  vitality, 
and  tightening  the  ligature  at  intervals,  so  that  the  tumor 
shall  slough  off,  which  it  will  do  in  a  period  varying  from 


NASO-PHAETXGEAL    TUMOES.  199 

four  or  fire  daj's  to  a  fortnight  or  more.  The  stench  which 
arises  during  this  process  is  said  to  be  unbearable  to  patient  as 
■well  as  to  attendants.  To  prevent  suffocation  by  the  falling 
of  the  polyp  upon  the  larynx,  Graefe,  in  whose  practice  an 
accident  of  this  kind  occiuTed,  has  recommended  the  passage 
through  the  body  of  the  polyp  of  a  thread  which  is  secured  out- 
side of  the  mouth,  and  by  means  of  which  the  extraction  of  the 
tumor  is  facilitated.  But,  even  wdth  this  precaution,  death  by 
suffocation  has  occurred  fi"om  impaction  of  the  polyp  in  the 
pharynx,  or  upon  the  lar^mx,  after  it  has  become  detached. 
It  is  therefore  highly  important  that  a  competent  and  well- 
instructed  assistant  should  be  constantly  at  the  side  of  the 
patient,  after  an  operation  of  this  kind,  until  the  mass  has 
come  away,  that  he  may  not  be  choked  to  death  with  it  in  his 
sleep. 

The  pain  attending  this  operation  is  said  to  be  yery  great, 
and  often  causes  swelling  of  the  throat  and  of  the  face;  in 
addition  to  which,  oedema  of  pharynx  and  larynx  may  ensue, 
necessitating  tracheotomy. 

The  polyp  itself,  too,  sometimes  increases  in  size,  necessitat- 
ing the  use  of  incisions  to  give  yent  to  some  of  its  contents. 

It  would  appear  good  practice  always  to  make  incisions  in 
the  tumor  after  an  operation  of  this  kind,  in  order,  in  the  first 
place,  to  reduce  its  size,  by  loss  of  blood  from  its  substance, 
and,  in  addition,  to  provide  a  yent  in  advance  for  the  products 
of  decomposition  as  they  accumulate. 

It  is  only  in  cases  where  there  is  more  or  less  of  a  pedicle  to 
the  tumor,  that  the  operation  of  ligature  is  likely  to  be  success- 
ful. In  tumors  with  broad  attachments,  especially  if  there  are 
prolongations  into  the  adjoining  cavities,  operations  of  a  much 
more  serious  nature  are  necessary  for  the  complete  removal  of 
the  growth. 

In  some  instances  the  soft  palate  has  been  divided  in  order 
to  afford  access  to  the  growth.  This  operation  dates  fi-om  the 
beginning  of  the  last  century,  and  has  been  fi-equently  per- 
formed in  our  own  time. 

Sometimes  the  entire  palate  and  uvula  is  slit,  but,  where 
possible,  the  palate  alone  is  to  be  divided.     By  this  means  the 


200  SPECIAL    AFFECTIONS    OF    THE    PHAKYIirX. 

tumor  can  be  more  readily  seized  with  forceps  and  excised,  and 
the  hemorrhage  better  controlled.  The  usual  plan  has  been, 
where  the  hemorrliage  was  excessive,  to  employ  the  hot  iron. 
Circumstances  determine  the  propriety  of  uniting  the  w^ound 
in  the  palate  by  suture  at  the  time  of  operation,  or  deferring 
union  to  a  subsequent  period  by  the  method  of  staphylorraphy, 
in  order,  as  recommended  by  Nelaton,  to  be  able  to  apply  caus- 
tics to  the  stump,  or  parts  from  which  the  tumor  has  been 
removed. 

In  some  instances  the  palate  has  been  divided  merely  to 
afford  the  oj^portunity  of  ligating  the  polyp ;  in  others,  in  order 
to  admit  of  its  extraction  by  the  forceps.  These  cases  occurred 
chiefly  in  children,  whose  parts  were  too  small  to  admit  of  the 
finger  beliind  the  palate  without  danger  of  suffocation. 

Prof.  Nelaton  has  not  only  divided  the  palate,  but  has  dis- 
sected the  mucous  membrane  off  fi-om  the  hard  palate,  a  piece 
of  which  has  then  been  cut  out  in  order  to  gain  access  to  a 
tumor  growing  from  the  base  of  the  skull,  and  to  enable  him 
to  scrape  away  the  periosteum  from  the  base,  and  thus  the 
better  prevent  a  recurrence.  In  an  operation  of  this  kind,  it 
would  be  well  to  remove  the  periosteum  from  the  hard  palate 
in  connection  with  the  mucous  membrane,  in  the  expectation, 
after  reunion,  of  a'  reproduction  of  bone,  the  same  as  takes 
place  after  Langenbeck's  operation  of  uranoplasty  for  cleft  of 
the  hard  palate. 

Prof.  Nelaton  has  also  removed  the  entire  palate  in  cases 
where  its  structure  was  involved  in  that  of  the  tumor. 

A  still  more  serious  operation  is  sometimes  requisite  to  ac- 
complish the  extirpation  of  these  troublesome  tumors.  This 
consists  in  the  partial  or  complete  removal  of  the  upper  maxil- 
lary bone,  as  may  be  necessary  on  account  of  the  size  and  situa- 
tion of  the  growth.  Access  to  the  tumor  is  made  from 
the  exterior  by  the  incisions  usually  practised  by  surgeons  for 
partial  or  complete  removal  of  the  upper  jaw,  or  for  its  resection 
in  cases  of  growths  involving  the  antrum.  In  some  cases  it  is 
possible,  as  in  a  case  operated  upon  by  Larghi,'  to  reach  the 

1   Gaz.  Med.,  Paris,  1867,  p.  617. 


FASO-PHAEYNGEAL    TUMOES.  201 

c 

growtli.  by  means  of  an  anterior  opening  through  the  superior 
maxillary  bone,  executed  behind  the  everted  upper  lip. 

The  operation  by  removal  of  the  upper  maxillary  bone  has 
terminated  fortunately  in  a  number  of  instances  ;  but  it  is  often 
attended  with  a  great  deal  of  danger,  not  merely  fi-om  the  re- 
moval of  the  bone,  itself  a  serious  procedure,  but  because  the 
nature  of  the  growth  necessitating  an  operation  of  this  kind  is 
apt  to  be  one  to  present  unfortunate  complications. 

In  illustration  of  this  point,  I  translate  in  detail  from  the 
Gazette  des  Hopitatix,  Aug.  9th,  1870,  et  seq.,  the  following 
record : — 


"  Naso-jpTiaryiigeal  Polyp  of  Midtijple  AttacJiments  and  Rapid 
Growth. — Ablation  of  the  Superior  Maxilla. — Evulsion  of 
the  Polyp. — Extensive  Hemorrhage  '  Syncope. — Entrance 
of  Blood  into  the  Air-passages. — Iimnediate  DeatliP 

"Bachelet,  set.  16,  hopital  Lariboisiere,  Salle  Saint  Louis. 
Good  constitution,  marked  embonpoint,  color  fresh  and  rosy. 
ISTo  trace  of  anaemia.  Health  excellent.  Several  cervical  gan- 
glia a  little  large,  dating  from  infancy. 

"  Apparent  onset  of  the  disease  last  October,  by  a  little  diffi- 
culty of  respiration,  with  occlusion  of  the  left  nasal  fossa,  and  a 
series  of  epistaxes  which  ceased  spontaneously  during  Decem- 
ber. Towards  this  period  the  cheek  began  to  swell,  and  hear- 
ing gradually  disappeared  on  the  left  side. 

"  Condition  on  entering  hospital.^  June  \Hh. — A  tumor 
upon  the  left  cheek  the  size  of  a  turkey-hen's  Q^^.,  rather 
firm,  slightly  movable,  indolent  to  the  touch,  non-adher- 
ent to  the  skin,  and  without  change  of  color  except  some  veno- 
sities.  Slight  swelling  at  the  inferior  portion  of  the  temporal 
fossa.  Occlusion  of  left  nasal  fossa  by  a  tumor  visible  a  short 
distance  within  the  nostril.  Depression  of  the  soft  palate  by  a 
tumor  in  the  pharynx  readily  recognized  by  the  touch,  but  with- 
out the  ability  to  ascertain  its  pedicle.  Commencing  exophthal- 
mia  of  left  side. 

"  JSToisy  respiration,  occurring  only  by  the  mouth  ;  complete 
deafness  of  left  side.     Deglutition  easy.     ITo  pains.     Yision  in- 


202  SPECIAL   AFFECTIONS    OF   THE   PHARYNX. 

tact.  Sensibility  of  integument  conserved  tlirougliout.  Cere- 
bral functions  normal. 

"  The  diagnosis  was  easily  made.  There  was  a  veiw  Yolumi- 
nous  naso-pharyngeal  polyp  of  the  left  side  of  the  base  of 
the  skull,  filling  the  pharynx  and  sending  prolongations  into 
the  nasal  fossa,  the  maxillary  sinus,  the  orbit,  the  pterygo-maxil- 
lary  notch,  and  possibly  the  temporal  fossa. 

"  A  preliminary  resection  of  the  upper  maxilla  appeared  indis- 
pensable, and  as  no  contra-indication  was  presented,  the  patient 
was  subjected  to  the  usual  preparations,  and  on  June  29th  the 
operation  was  performed  in  the  following  manner : — 

"  The  patient  being  chloroformed,  not  without  difficulty,  M. 
Yerneuil,  with  a  view  of  avoiding  the  accumulation  of  blood  in 
the  mouth,  made  two  incisions  in  the  cheek,  one  vertical,  the 
other  oblique  externally,  without  wounding  the  mucous  mem- 
brane. He  could  thus  cut  the  two  osseous  pillars,  molar  and 
nasal,  by  means  of  the  cutting-pliers  of  Liston,  without  the  pas- 
sage of  a  drop  of  blood  into  the  mouth. 

"  Dissection  of  the  malar  fragment,  extraction  of  the  canine 
tooth,  division  of  the  intermaxillary  suture,  and  extraction  by 
traction  of  the  maxillary  bascule,  were  all  performed  rapidly 
and  without  hemorrhage  into  the  mouth.  The  polyj?,  when 
isolated,  was  found  surrounded  by  a  venous  network  extremely 
developed,  which  jetted  out  blood  in  abundance.  The  pedicle 
of  this  was  without  exaggeration  three  centimetres  in  diameter, 
and  was  inserted  deeply  against  the  vault  of  the  pharynx  in 
such  manner  that  it  was  impossible  to  grasp  it.  Before  reaching 
it,  M.  Yerneuil  attacked  the  pol}^3,  which  he  broke  up  in  re- 
moving it  lobe  by  lobe.  As  the  blood  flowed  in  streams,  it  was 
sopped  up  with  compressed  sponge.  He  was  finally  able  to  apply 
a  pair  of  forceps  upon  the  large  pharyngeal  pedicle  of  the  tumor, 
but  this  did  not  prevent  the  blood  from  flowing  in  great  quan- 
tity. The  patient,  who  became  stifled,  cried  and  ejected  blood 
continually  ;  was  raised,  and  cold  water  was  projected  into  the 
mouth  from  an  irrigator  in  an  attempt  to  arrest  the  hemorrhage. 
Fearing  to  provoke  syncope,  he  was  laid  down  again  imme- 
diately after.  He  was  hardly  laid  down  when  syncope  occurred ; 
upon  which  M.  Yerneuil  introduced  into  the  larynx  an  adult  sil- 


ISTASO-PHAEYJSTGEAL    TUMORS.  203 

ver  canula  to  insufflate  the  air  and  suck  out  tlie  blood.  He  was 
able  in  this  way  to  till  his  mouth  several  times  with  blood,  and 
to  disembarrass  the  bronchial  tract  in  part  of  this  fluid,  while  at 
the  same  time  his  assistants  pressed  alternatively  uj^on  the  belly. 
At  a  given  moment  the  pulsations  of  the  heart  became  apprecia- 
ble as  well  as  the  pulse  at  the  wrist ;  the  patient  respired  and 
began  to  cry,  which  again  gave  rise  to  hemorrhage,  momentarily 
arrested  by  the  syncope.  The  same  manoeuvres  were  recom- 
menced, the  blood  was  sucked  out,  the  air  insufflated,  the  head 
was  lowered,  but  efforts  were  vain ;  the  patient  did  not  revive, 
but  succumbed  in  spite  of  efforts  at  resuscitation,  prolonged  for 
more  than  half  an  hour." 

This  account  was  read  at  the  Societe  Imperiale  de  Chirurgie, 
at  their  meeting  on  June  29,  1870,  and  was  followed  by  a  dis- 
cussion as  to  the  cause  of  death — whether  syncope  or  as23hyxia  ; 
death  being  generally  ascribed  to  asphyxia. 

At  the  meeting  of  July  6,  1870,  M.  Yerneuil  presented  the 
naso-pharyngeal  polyp  of  which  he  had  spoken  at  the  last  meet- 
ing, and  gave  the  following  details  of  the  autopsy. 

"  A  complete  autopsy  could  not  be  made,  consequently  we 
were  unable  to  assure  ourselves  of  the  presence  of  blood  in  the 
air-passages  ;  but  in  examining  at  leisure  the  region  operated, 
we  have  secured  important  details  relative  to  the  implantation 
of  the  tumor. 

"  It  had,  without  doubt,  originated  on  the  left  side,  but  it  had 
progressively  extended  over  a  very  large  surface.  It  had  ad- 
hered, first,  to  the  entire  pharyngeal  face  of  the  basilary  apo- 
physis ;  second,  to  the  entire  inferior  face  of  the  body  of  the 
sphenoid ;  the  sphenoidal  sinus,  largely  open  and  strongly 
dilated,  enclosed  a  lobe  of  the  tumor  of  the  volume  of  a  large 
nut  and  without  adherence  ;  third,  to  the  right  lateral  face  of 
the  vomer,  to  the  extent  of  about  one  centimetre ;  fourth,  to 
the  point  of  the  petrous  portion  of  the  temporal  bone  upon  a  sur- 
face as  large  as  a  finger-nail ;  fifth,  to  the  base  of  the  pterygoid 
apophysis,  which  had  almost  entirely  disappeared,  and  was  only 
represented  by  osseous  debris  mingled  with  fibrous  tissue ;  upon 
an  osseous  fioating  lamella  the  external  insertion  of  the  ptery- 
goidien  was  distinctly  recognized. 


204  SPECIAL    AFFECTIOl^fS    OF    THE   PHAETNX. 

"Below,  at  the  side  of  the  pharynx,  the  insertion  of  the  polyp 
was  distinctl}^  limited  to  the  neighborhood  of  the  anterior  por- 
tion of  the  occipital  foramen.  No  adhesion  to  the  occipito-atloid 
ligament  or  to  the  bodies  of  the  vertebrse.  The  mucous  mem- 
brane of  the  Tertebral  wall  of  the  pharynx  was  absolutely 
healthy. 

"The  left  nostril  was  very  much  enlarged  by  the  disjDlacement 
of  the  septum,  which  had  become  applied  exactly  against  the 
external  wall  of  the  right  nasal  fossa ;  this  last  was  com- 
pletely obliterated.  Some  osseous  debi-is  still  represented  the 
septum,  which  separated  the  left  nasal  fossa  from  the  maxillary 
sinus  of  the  same  side.  The  nasal  and  maxillary  lobes  of  the 
tumor  were  distinct.  The  anterior  and  inferior  border  of  the 
orbit  had  been  implicated  during  the  operation,  but  the  rest  of 
the  floor  of  the  orbit  had  been  destroyed,  by  compression  doubt- 
less, in  such  manner  that,  behind  and  below,  the  orbital  cavity 
communicated  extensively  with  the  wound. 

"  Finally,  and  this  is  perhaps  the  most  important  point  of  this 
anatomical  exploration,  there  was  observed  in  the  neighborhood 
of  the  foramen,  torn  anteriorly,  a  large  perforation  of  the  base 
of  the  cranium,  capable  of  admitting  the  terminal  phalanx  of 
the  thumb,  and  permitting  the  penetration  of  a  lobe  of  the 
tumor  w^hich  had  raised  the  dura  mater,  without  liaving  at  all  con- 
tracted any  "adherence  with  it.  It  would  have  been  important 
to  open  the  cranium,  to  learn  if  the  brain  or  its  membranes  in 
this  vicinity  had  suffered  from  intrusion  of  the  tumor.  No 
trace  of  inflammation  existed  on  the  inferior  face  of  the  cranial 
periosteum. 

"  It  had  been  believed  that  the  extii-pation  of  the  polyp  had 
been  complete,  but  this  had  not  been  the  case.  There  had  been 
left  behind  a  voluminous  lobe,  which,  departing  fi-om  the  base 
of  the  pterygoid  apophysis,  proceeded  directly  outwards,  filled 
up  the  lateral  wall  of  the  pharynx,  then  insinuated  itself  between 
the  posterior  border  of  the  ascending  branch  of  the  maxilla  and 
the  anterior  border  of  the  sterno-mastoid,  and  reached  finally  by 
its  free  extremity  to  the  summit  of  the  mastoid  apopJiysis  and 
the  deep  surface  of  the  integument.  This  lobe  might  be  called 
the  superior  cervical;  it  was  enveloped  throughout  by  loose  con- 


ISTASO-PHAETI^GEAL    TUMOES.  205 

junctive  tissue  ;  its  enucleation  was  easy.  Towards  its  anterior 
face  was  attached  a  small  j&brous  tissue  of  the  size  of  an  almond, 
almost  entirely  free,  or  at  least  without  connection  with  the 
bones.  The  reporter  did  not  know  whether  the  existence  of  fi-ee 
lobes  had  yet  been  noted  in  cases  of  naso-pharyngeal  fibroraes. 
There  is  still  to  note  a  final  particularity  not  less  interesting.  It 
is  generally  admitted,  and  with  reason,  that  the  tumors  in  ques- 
tion originate  from  the  periosteum,  and  leave  the  subjacent 
osseous  structures  intact,  in  such  manner,  that  if  the  extraction 
is  complete,  these  surfaces  are  denuded,  but  uninjured. 

"  M.  Yerneuil  has  been  able,  in  another  observation,  to  assure 
himself  of  the  reality  of  this  fact,  but  such  was  not  the  case  here. 
It  has  already  been  said  that  the  base  of  the  pterygoid  apophysis 
had  disappeared,  not  by  alisorption,  but  by  a  sort  of  interstitial 
invasion  of  the  osseous  tissue  by  the  fibrous  tissue.  An  analo- 
gous disposition  was  encountered  at  the  basilary  apojDhysis.  After 
having  successively  extirpated  the  nasal,  buccal,  and  maxillary 
lobes,  he  had  seized  the  pharyngeal  lobe  to  its  root  with  strong 
forceps,  and  had  toril  it  off  completely — in  appearance  at  least. 
However,  the  surface  of  implantation  at  the  basilary  apophysis 
remained  unequal  and  nodular ;  the  touch  gave  the  sensation  of  a 
spongy  surface,  studded  with  osseous  debris.  At  the  autopsy  he 
recognized,  in  fact,  at  this  point,  a  substance  composed  of  frag- 
ments of  spongy  tissue,  of  layers  of  fibrous  tissue,  and  of  several 
small  rounded  fibrous  tumors,  regular,  of  the  volume  of  a  grain 
of  wheat  or  a  pea.  In  enucleating  this  substance  with  a  blunt 
instrument,  he  found  that  it  occupied  the  very  centre  of  the 
basilary  apophysis,  which  was  excavated  and  reduced,  on  the 
side  of  the  cranial  cavity,  to  a  very  thin  layer  of  osseous  tissue. 
In  pressing  feebly  with  the  blunt  instrument  against  this  layer, 
he  readily  penetrated  to  the  dura  mater. 

"  If,  then,  to  destroy  the  roots  of  the  tumor  at  this  point,  he  had 
rasped,  or  applied  the  actual  cautery,  he  would  have  perforated 
the  thin  osseous  barrier.  If  he  had  abstained,  the  intimate  com- 
bination of  the  fibrous  tissue  with  the  'osseous  tissue,  and  the 
persistence  at  this  point  of  the  small  circumscribed  fibrous  lobes, 
would  almost  inevitably  have  been  the  origin  of  a  reproduction, 

"  Regarding  the  structm-e  of  the  moibid  j)roduction,  it  was  al- 


206  SPECIAL    AFFECTIONS    OF   THE    PHAEYISTX. 

together  similar  to  that  of  these  fibromes,  that  is  to  say,  formed 
of  fibrous  tissue,  conjunctive  elements  in  every  degree  of  evolu- 
tion, and  an  incredible  quantity  of  vessels,  some  of  which 
had  attained  the  calibre  of  2  millimetres. 

"  The  jDreceding  observations  are  of  a  nature  to  extenuate  some 
little  the  regrets  inspired  by  this  fatal  operation.  If  death  had 
not  occurred  suddenly,  it  would  have  been  the  almost  inevitable 
consequence  of  cranial  perforation  and  of  consecutive  meningo- 
encephalitis." 

In  the  discussion  which  followed,  M.  Forget  "  recalled  an 
analogous  case  presented  by  him  to  the  Society  a  dozen  years 
previous,  concerning  a  naso-pharyngeal  polyp  in  a  young  boy 
incompletely  operated  upon  through  the  nasal  passages  by  M. 
Huguier.  At  the  autopsy  which  followed  close  upon  the  opera- 
tion, there  was  discovered  the  existence  of  multiple  tumors  in 
the  thickness  of  the  bone  at  the  base  of  the  cranium,  and  as  far  as 
beneath  the  dura  mater.  One,  among  others,  filled  the  sphenoidal 
sinus,  and  appeared  as  if  pediculated  upon  the  sella  tursica.  The 
multiplicity  of  origin  and  the  plurality  of  points  of  insertion  of 
these  neoplasms,  the  solidarity  which  exists  between  them  and 
the  osseous  tissue  of  the  base  of  the  cranium,  their  very  great 
vascularity,  indicate  sufficiently  that  they  are  something  else 
than  true  polyps,  and  that  they  are  an  affection  of  a  separate 
lesion  of  the  spongy  tissue  of  the  base  of  the  cranium,  peculiar 
to  young  subjects  and  those  in  whom  the  bones  are  growing.  .  . . 
In  the  service  of  Boyer,  Roux  wanted  to  operate  contrary  to  the 
opinion  of  the  master.  There  was  grave  hemorrhage,  necessitat- 
ing the  tampon,  and  the  young  man  was  carried  to  his  bed  in- 
completely disembarrassed  of  his  supposed  polyp. 

"  The  same  thing  occurred  to  Lisfi-anc,  who  abandoned  the 
completion  of  the  operation ;  and  the  little  patient,  rendered 
exsanguine,  succumbed  at  the  end  of  a  few  days. 

"  Adding  these  two  facts  to  eight  others  which  our  colleague 
has  been  able  to  collect  in  the  various  records,  eleven  in  all,  it  is 
questionable  if  it  is  not  better,  with  Boyer,  to  interdict  all 
attempts  at  extraction  in  such  cases." 


JSTASO-PHAEYNGEAL    TUMORS.  207 

Prof.  B.  Laiigenbeck,  of  Berlin,  has  proposed  and  pnt  into 
practice  a  method  of  reaching  the  growth,  which  consists  in  the 
resection  of  the  nasal  process  of  the  upper  maxillary  bone  and 
the  nasal  bone.  This  operation  has  been  performed  with  more 
or  less  variation  by  other  surgeons,  and  in  suitable  cases  with 
successful  results.  It  partakes  of  the  objection  to  many  other 
operations,  that  in  too  many  instances  it  does  not  permit  free  access 
to  the  parts,  so  that  the  extirpation  is  sometimes  incomplete. 

In  other  instances  the  nose  has  been'  turned  down,  and  the 
growth  removed  successfully  by  various  appliances.  This  mode 
of  access  has  recently  been  resorted  to  successfully  in  this  country 
by  Dr.  Cabot.^ 

Dr.  Achille  Bonnes^  succeeded  in  the  ablation  of  one  of  these 
polyps  by  means  of  a  metallic  nail  attached  to  a  thimble. 

Dr.  E.  Cutter,'  of  Boston,  has  devised  a  very  ingenious 
adaptation  of  the  wire-loop  to  the  mechanism  of  an  ecraseur,  by 
which  an  instrument  small  enough  for  use  through  the  nostrils, 
or  behind  the  palate,  can  be  readily  employed  in  favorable  cases  ; 
and  with  wiiich  he  has  operated  successfully  and  satisfactorily. 

The  use  of  the  galvano-cautery  has  been  resorted  to  for  the 
removal  of  these  polyps  ;  and  where  an  apparatus  is  at  hand,  it 
is  no  doubt  better  than  the  ligature  or  the  knife,  whether  em- 
ployed through  the  mouth  or  the  nose,  or  after  access  to  the  parts 
has  been  obtained  by  means  of  some  one  or  other  of  the  surgical 
operations  which  have  been  mentioned.  The  cautery  sears  the, 
vessels  as  it  cuts  its  way  through  the  structures,  and  thus  greatly 
lessens  the  danger  from  hemorrhage.  This  method,  first  proposed 
and  executed  by  Prof.  Middeldorpf,  has  been  employed  with 
success  by  Kelaton,  Dieffenbach,  Yoltolini,  Semeleder,  Neu- 
mann, von  Bruns,  Brenner  and  others. 

Electrolysis,  too,  has  been  resorted  to  successfully  for  the 
removal  of  these  tumors,  by  disintegration  and  absorption. 

Prof.  Xelaton  has  reported  several  cases  treated  by  electro- 
lysis.    One  was  completely  cured,  two  were  very  nearly  cured, 

^  Boston  Med.  and  Surg.  Jour.,  Feb.  9tli,  1871,  p.  95. 

■^Bull.  Gen.  de  TMra/p.,  Oct.  30th,  1869,  p.  364. 

*  Boston  Med.  and  Surg.  Jour.,  Nov.  24th,  1870,  p.  339,  illustrated. 


208  SPECIAL    AFFECTIOlSrS    OF    THE    PHAEYISTX. 

one  returned,  and  in  one  case  death  ensued  from  typhoid  fever 
during  the  diminution  of  the  tumor.  Fischer  reports  a  case 
entirely  cured  within  two  months,  after  six  applications  of  the 
electric  current.  Prof,  von  Bruns '  reports  a  case  of  success  in 
a  man,  23  years  of  age,  with  a  large  fibrous  tumor  of  the  pharynx, 
who  had  been  operated  upon  three  years  pre^dously,  after  split- 
ting the  soft  palate,  by  the  constrictor  of  Maisonneuve,  A 
recurrence  had  taken  place,  and  the  growth  not  only  filled  the 
entire  pharynx,  so  that  it  not  only  projected  into  the  mouth 
through  the  artificial  cleft,  reaching  as  far  as  the  lower  border 
of  the  palate,  but  sent  a  prolongation  through  the  left  nostril  to 
its  Yery  external  opening,  and  had  pushed  the  left  eyeball  out- 
wards, downwards,  and  forwards  to  the  distance  of  several  lines. 
One  needle  from  the  battery  was  passed  into  the  pharyngeal  por- 
tion of  the  polyp,  and  another  into  the  nasal  portion.  From  May, 
1869,  until  March,  1870, 130  such  applications  were  made,  and  the 
polyp  had  become  so  far  destroyed  and  contracted  that  it  could 
no  longer  be  seen  from  the  mouth  or  from  the  nose,  though  its 
remains  could  be  felt  by  the  finger  from  the  mouth  and  from' 
the  nostril,  in  the  latter  instance  only  by  burying  the  finger 
within  the  nostril  to  a  depth  of  two  inches.  The  improvement 
began  with  the  institution  of  the  electrolytic  treatment. 

Although  the  naso-pharyngeal  polyp  is  such  a  serious  affection 
that  its  removal  may  be  accompanied  by  death,  or  be  followed 
by  a  fatal  result  from  hemorrhage,  asphyxia,  surgical  fever,  or 
pysemia,  it  must  not  be  forgotten  that  cases  sometimes  undergo 
spontaneous  cures. 

Dr.  Komm  ^  narrates  the  case  of  a  man  of  28  years  of  age,  who 
had  suffered  for  a  long  time  from  a  j)olyp  which  pressed  the 
palate  strongly  forwards  into  the  mouth.  It  filled  the  entire 
posterior  portion  of  the  pharynx,  and  was  so  intimately  con- 
nected with  the  surrounding  tissues  that  ligation  was  not  avail- 
able. An  attempt  was  made  to  excise  it,  but  the  patient  would 
not  suffer  the  completion  of  the  operation.  The  patient  was 
placed  in  a  state  of  rest  as  to  mind  and  body ;    ice  was  applied 

^Die  Gahano-Chinirgie,  Tiibingen,  1870,  p.  85. 
"  Schmidt's  Jahrb.  XXX.  p.  61. 


WOUNDS    OF   THE    PHAEYNX.  209 

upon  tlie  head  and  around  the  throat ;  and  nutrition  maintained 
bj  enemata.     The  polyp  underwent  spontaneous  absorption. 

Occasionally,  too,  spontaneous  sloug-hing  of  these  tumors  oc- 
curs. In  a  case  under  the  care  of  Mr.  H,  C.  Johnson,'  recur- 
rence took  place  after  the  original  tumor  had  been  extracted  by 
curved  f  orcej)s  passed  round  the  palate.  While  the  propriety  of 
dividing  the  palate,  so  as  to  gain  access  to  the  base  of  the  growth, 
was  under  discussion,  rapid  sloughing  took  place  spontaneously, 
and  removed  every  trace  of  the  tumor. 

In  a  case  under  the  care  of  Mr.  Birkett,"  the  hemorrhage 
from  the  polyp  was  so  great  as  to  necessitate  ligation  of  the 
common  carotid  artery.  The  whole  tumor  sloughed  away 
through  a  sinus  which  formed  in  the  cheek,  and  seven  years 
afterwards  the  patient  was  reported  as  perfectly  well,  with  no 
evidence  of  the  tumor,  and  with  the  sinus  in  the  cheek  healed. 

WOUXDS  OF  THE  PHAEYNX. 

Accidental  wounds  of  the  pharynx  sometimes  occur,  and  pre- 
sent some  difficulty  in  their  management  on  account  of  the 
embarrassment  in  suj^plying  nourishment.  Food  and  medicine 
should  be  administered  by  the  rectum  as  far  as  possible,  on  ac- 
count of  the  dauger  of  the  passage  of  food,  when  swallowed, 
into  the  cellular  tissue  of  the  neck.  In  most  cases,  however, 
the  patient  will  manifest  but  little  desire  to  swallow,  on  account 
of  the  pain  attending  the  act  of  deglutition. 

Occasionally  wounds  of  the  pharpix  give  rise  to  the  forma- 
tion of  an  abscess  beneath  the  mucous  membrane.  PromjDt 
evacuation  of  the  contents  of  the  abscess  is  called  for.  A  case 
of  this  kind  came  under  the  author's  care  a  few  years  ago,  in 
which  the  accident  was  produced  by  a  stick  of  wood  in  the 
mouth,  the  patient  falling  prone  and  striking  upon  the  stick.  It 
is  quite  likely  that  a  splinter  was  broken  off  in  the  pliarynx,  but 
as  the  stick  had  not  been  preserved,  this  point  could  not  be 
determined. 

Wounds  of  the  pharjmx,  communicating  externally,  are  some- 

^Brit.  Med.  Jour.,  Jan.  1858,  p.  61.     Guy's  Hosp'l  Bep.  1867,  p.  157. 
2 Brit.  Med.  Jour.  1868,  p.  119.     Ouys  HospH  Bep.  1867,  p.  167. 

14 


210  SPECIAL    AFFECTIONS    OF   THE    PHAEYISTX. 

times  met  witli  as  the  result  of  attempts  at  suicide.  In  these 
instances  the  wound  in  the  throat  is  made  above  the  hyoid  bone 
or  below  it.  In  the  former  instance  the  root  of  the  tongue  is 
wounded ;  in  the  latter,  the  epiglottis  is  often  implicated,  and 
it  has  sometimes  even  been  pushed  down  into  the  lai-jTix,  or 
been  drawn  into  it  during  treatment, — in  either  case  producing 
suffocation.  It  is  therefore  recommended  to  remove  any  frag- 
ment of  the  ej)iglottis  that  is  already  nearly  divided.  After 
hemorrhage  is  arrested,  the  parts  are  brought  together  by  su- 
ture, room  being  left  for  the  discharge  of  sputa  and  the  inflam- 
matory products  which  will  present  at  the  wound.  Swallowing 
being  difficult  or  impracticable,  nourishment  is  maintained  by 
the  use  of  the  stomach  tube,  or  by  allowing  liquid  aliment  to 
trickle  down  into  the  oesoj)hagus,  as  it  were.  If  this  be  im- 
practicable, the  nourishment  should  be  administered  by  enema. 
Medicine  may  be  administered  hypodennically  or  by  enema. 

In  the  treatment  of  wounds  of  the  pharynx  Prof.  Gross  re- 
commends that  the  suture  of  the  pharyngeal  wound  itself  be 
cut  oif  close  to  the  knot,  so  that  the  loops  may  fall  into  its  cavity 
and  thus  descend  into  the  stomach. 

The  pharynx  is  occasionally  wounded  diu-ing  the  perform- 
ance of  a  surgical  operation.  A  singular  chirurgical  wound  of 
the  vault  of  the  pharynx  is  recorded  as  having  occurred  under 
the  following  unusual  circumstances.  In  a  case  of  obstinate  sub- 
orbital neuralgia.  Prof.  Linhart,  of  "Wurzburg,  after  the  failure 
of  many  efforts  at  relief,  including  section  of  the  affected  nerve, 
determined  to  cut  off  the  inferior  maxillary  nerve  behind  the 
malar  branch,  as  well  as  the  posterior  dental  nerves,  to  prevent 
recurrence  in  those  branches.  In  order  to  avoid  the  disfigure- 
ment left  by  the  method  of  Dr.  Caniochan,  of  New  York,  he  made 
an  incision  which  enabled  him  to  raise  the  lower  eyelid,  and 
divide  the  tarso-orbital  membrane  in  scraping  the  border  of  the 
orbit.  The  myrtiform  pavilion  of  a  canulated  sound  was  passed 
between  the  lower  floor  of  the  orbit  and  the  globe  of  tlie  eye,  as 
far  as  the  summit  of  the  orbit.  The  eye  being  held  up,  the 
curved  extremity  of  the  galvano-caustic  apparatus  of  Middel- 
dorpff,  used  in  the  cauterization  of  strictures,  was  introduced  to 
the  most  internal  angle  of  the  suborbital  fissure,  and  applied 


WOUl^fDS    OF   THE    PHAEYl^rX.  211 

firmly  from  before  backward  ;  the  current  was  passed,  and  the 
pomt  occupied  bj  the  cautery  was  instantaneously  destroyed, 
when  the  instrument  penetrated  from  before  backward  without 
any  resistance.  On  soundino;  the  wound  it  was  found  it  had 
penetrated  to  the  bones  at  the  base  of  the  skull.  The  cm-rent 
was  again  passed,  and  the  beak  of  the  instrument  was  turned  in- 
wards and  glided  along  the  base  of  the  skull.  The  cautery 
penetrated  to  the  cephalic  portion  of  the  pharjmx,  immediately 
behind  the  posterior  orifice  of  the  nasal  fossa,  and  after  the 
operation  air  issued  by  the  orbit  when  the  patient  used  the  hand- 
kerchief and  when  he  coughed.  The  operation  was  tedious  and 
bloody,  but  successful. ' 

1  {Vierteljahrschrift  fur  die  pralctische  Heilkunde,  t.  11,  1860.)     Arch.  Gen. 
de  Med.,  Nov.,  1860. 


212  SPECIAL    AFFECTIOl^S    OF   THE    (ESOPHAGUS. 


CHAPTER   XI. 

SPECIAL    AFFECTIONS    OF   THE    (ESOPHAGUS. 
OESOPHAGITIS. 

iNFLAiviMATioisr  of  the  oesopliagus  is  of  rare  occurrence.  It  is 
sometimes  produced  by  mechanical  injury  from  the  passage  of 
a  foreign  body,  or  of  a  surgical  instrument,  and  occasionally 
by  the  swallowing  of  hot  and  acrid  fluids.  Chronic  inflam- 
mation of  the  oesophagus,  followed  by  abscess  and  ulceration, 
sometimes  results  during  the  course  of  caries  of  the  spine,  and 
in  cases  of  tumors  connected  with  the  oesophagus  or  pressing 
upon  it.  Inflammation  of  the  oesophagus  would  be  treated  on 
general  antiphlogistic  principles,  with  the  use  of  only  bland  and 
mucilaginous  articles  of  diet,  or  the  administration  of  nutriment 
by  the  rectum. 

CONGENITAL  OCCLUSION  OF  THE  CESOPHAGUS. 

Congenital  occlusion  of  the  oesophagus  is  sometimes  met  with, 
and  it  is  one  of  those  malformations  irremediable  by  surgery. 
The  existence  of  this  condition  may  be  suspected  when  the  child 
takes  the  breast  readily,  but  is  unable  to  swallow  the  nutriment 
and  rejects  it  by  the  mouth.  If,  as  often  happens,  there  be  a 
communication  with  the  trachea,  the  attempt  to  swallow  will  be 
followed  by  symptoms  of  suffocation,  the  result  of  the  presence 
of  food  in  the  air-passage.  On  inspection,  the  mouth  and  fauces 
appear  normal.  On  attempting  to  pass  a  bougie  along  the 
oesophagus  its  progress  will  become  arrested  in  a  sort  of  cul  de 
sac.  The  occlusion  is  usually  found  in  the  uj^per  portion  of  the 
CESophagus. 

A  number  of  cases  of  this  malformation  have  been  recorded. 
Holmes,  in  his  treatise  on  the  Surgical  Affections  of  Childhood, 
mentions  three  which  are  reported  in  the  Pathological  Trans- 
actions (vol.  iii.,  p.  91),  (vol.  vii.,  p.  52),  (vol.  viii,,  p.  173).  The 
obliteration  in  the  first  case  commenced  about  an  inch  below 


CO]N'GENITAL    OCCLUSION^    OF   THE    CESOPHAUUS.  213 

the  commenceraent  of  the  oesophagus,  and  continued  to  a  point 
just  above  the  origin  of  the  bronchi.  Swallowing  had  produced 
choking,  which  induced  the  diagnosis  of  a  communication  with 
the  trachea ;  and  an  opening  of  this  kind  was  discovered  after 
death.  The  child  was  nourished  bj  enemata,  and  died  on  the 
eleventh  day. 

In  the  second  case,  the  upper  and  lower  portions  of  the 
oesophagus  were  in  direct  communication  with  the  trachea, 
which  was  thus,  as  it  were,  doing  additional  duty  as  part  of  the 
gullet.  Dr.  Ogle,  who  reports  the  case,  believed  that  some  of 
the  milk  taken  by  the  child  may  have  reached  the  stomach. 
The  child  pei'ished  on  the  fourth  day. 

In  the  third  case  there  coexisted  malformation  of  the  heart 
and  great  vessels,  with  cyanosis.  The  trachea  communicated 
with  the  lower  part  of  the  oesophagus,  and,  Mr.  Holmes  thinks, 
must  have  communicated  with  the  upper  part  also,  inasmuch  as 
attempts  at  swallowing  always  produced  dyspnoea.  The  obli- 
teration extended  fi-om  the  end  of  the  pharynx  to  a  point  oppo- 
site the  bifurcation  of  the  trachea.  The  child  died  on  the 
twelfth  day. 

From  the  result  of  the  examinations  made  in  the  instances 
recorded,  Mr.  Holmes  justly  concludes  that  surgery  offers  very 
little  hope  of  remedying  or  overcoming  such  a  condition  by 
any  operative  procedure.  In  cases  where  .a  tracheal  fistula 
exists,  in  connection  with  obliteration  of  the  oesophagus,  he 
questions  whether  life  would  be  permanently  maintained,  even 
if  the  passage  of  food  could  be  restored,  and  he  does  not  think 
the  attempt  should  be  made  in  any  such  case.  Where  no  such 
communication  exists,  he  sees  no  objection  to  the  operation 
being  attempted,  after  due  explanation  to  the  parents  of  the 
fatal  nature  of  the  case.  The  object  would  be  to  cut  down 
upon  tlie  point  of  a  catheter  passed  along  the  pharynx,  and  then 
to  attempt  to  trace  the  obliterated  oesophagus  down  the  front  of 
the  spine,  until  its  lower  dilated  portion  is  found.  A  gum- 
catheter  would  then  be  passed  through  an  opening  made  in  the 
upper  portion,  and  so  on  into  the  stomach  through  the  lower  por- 
tion. If  the  two  portions  are  near  enough  to  be  connected  by 
silver   sutures   over   the   catheter,   and    if    the    latter   can   be 


214  SPECIAL    AFITECTIOlSrS    OF    THE    (ESOPHAGUS. 

retained  until  they  have  united,  Mr.  Holmes  thinks  that  perma- 
nent success  might  possibly  be  obtained. 

Mr.  Ryland '  refers  to  a  case  related  by  Dr.  Houston,*  and 
which  occurred  under  his  own  obseryation,  where  the  oesopha- 
gus communicated  with  the  posterior  part  of  the  trachea  by  a 
large  opening.  The  pharynx  was  unusually  wide,  and  termi- 
nated some  way  down  the  neck  in  a  cul  de  sac,  without  having 
any  connection  with  the  oesophagus.  The  larynx  and  its  mus- 
cles were  all  perfect.  This  infant  lived  about  twenty-four 
hours.  On  every  attempt  to  suck,  fits  of  coughing  immediately 
supervened,  threatening  suffocation  by  their  violence,  and  last- 
ing till  the  milk  was  all  disgorged  again.  The  only  way  in 
which  food  could  get  into  the  stomach  was  by  passing  through 
the  rima  glottidis  first,  and  then  reaching  the  oesophagus  from 
the  opening  in  the  posterior  part  of  the  trachea. 

Mr.  Annandale  ^  illustrates  the  pathological  appearances  of  the 
case  of  an  infant  who  died  in  forty-eight  hours  after  birth,  in 
which  the  upper  part  of  the  oesophagus  was  dilated  into  a  pouch 
three-tenths  of  an  inch  above  the  bifurcation  of  the  trachea,  into 
the  posterior  wall  of  which  it  entered  at  this  point.  Similar 
cases  reported  by  others  are  referred  to  in  his  article. 

CONGENITAL   FISTULE    OF    THE    OESOPHAGUS. 

As  has  been  mentioned  elsewhere,  a  fistule  of  the  oesophagus 
sometimes  remains  after  a  wound  of  that  tube,  or  after  the  dis- 
charge of  an  oesophageal  abscess,  the  result  of  the  retention  of 
a  foreign  body. 

A  few  cases  of  congenital  fistule  are  on  record.  The  evi- 
dences of  a  fistulous  opening  are  seen  on  some  part  of  the 
neck,  giving  discharge  every  day  to  several  drops  of  pus, 
a  drop  or  two  of  which  can  almost  always  be  pressed  out  of 
the  little  opening.  The  track  of  the  fistule  is  often  so  slender 
that  a  delicate  probe  cannot  be  passed  along  it  without  penetra- 
ting the  walls  of  the  fistule.     The  fistule  is  suj^posed  not  to  be 

^  A  Treatise  on  the  Diseases  and  Injuries  of  the  Laiynx  and  Trachea. 
'  Dublin  Hospital  Reports^  Vol.  V.,  p.  310. 
'  Edinb.  Med.  Jour.,  Jan.,  1869,  p.  598. 


CONGENITAL    FISTULE    OF    THE    (ESOPHAGUS.  215 

connected  with  the  air-passages,  in  consequence  of  the  failure 
of  every  attempt  to  pass  air  out  of  it  from  the  hmgs. 

If  the  opening  have  been  congenital,  it  will  probably  be 
found  on  inquiry,  as  in  a  case  reported  by  Dr.  J.  M.  Duncan,^ 
that  drops  of  milk  exuded  from  it  at  some  time  when  the  child 
was  suckling. 

The  position  of  the  fistulous  opening,  the  direction  taken  by 
an  exploring  probe,  and  some  history  of  the  escape  of  nutri- 
ment, can  alone  distinguish  it  from  other  fistules  of  the  neck 
which  open  externally  in  front  of  the  thyroid  cartilage,  or  to 
one  side  of  it,  and  which  originate  in  one  of  the  three  mucous 
bursse  in  this  situation,  most  frequently,  according  to  the 
researches  of  Giirlt,  in  the  infra-hyoid  bursa. 

I  have  seen  a  few  cases  of  fistulous  openings  in  the  neck, 
either  congenital,  or  of  life-long  standing  to  the  best  recollec- 
tions of  the  patient,  in  which  it  was  impossible  even,  in  one 
case,  by  cutting  down  upon  the  track  and  following  its  aj^parent 
entire  course,  to  find  whether  it  really  communicated  with  the 
pharynx  or  cesophagns,  or  not.  In  the  case  referred  to  no  cyst 
was  found  connected  with  the  thyro-hyoid  bursa,  though  the 
track  led  directly  to  the  hyoid  bone,  which  appeared  denuded 
of  its  periosteum.  This  was  scraped,  the  fistulous  track  cut 
out,  and  the  parts  brought  together,  with  some  benefit  as  far  as 
a  reduction  of  the  amount  of  discharge  was  concerned,  but 
failure  in  reference  to  any  obliteration  of  the  fistule,  which 
was  congenital,  and  existed  in  a  healthy  lad  some  twenty  years 
of  age. 

STEICTUEE    OF   THE   (ESOPHAGUS. 

Stricture  of  the  cesophagus  is  occasionally  congenital,  and, 
under  the  circumstances,  would  be  naturally  considered  as  ne- 
cessarily fatal.  That  this  is  not  so,  is  attested  by  a  case  narrated 
by  Dr.  Wilks ''  and  referred  to  by  Mr.  Holmes,"  in  the  follow- 
ing language : — 

1  Bdin.  Med.  Jour.,  Nov.,  1855. 
^  Pathological  Transactions,  XVII.,  138. 

'  The  Surgical  Treatment  of  the  Diseases  of  Infancy  and  Childhood. ,  3d 
Hit.,  p.  137. 


216  SPECIAL    APFECTIOlSrS    OF   THE    (ESOPHAGUS. 

"  The  patient  was  a  very  healthy  man,  and  well  nourished. 
He  died  at  the  age  of  seventy-four,  of  pneumonia,  having 
never  previously  had  a  serious  illness  during  the  whole  of  Dr. 
Eoote's  professional  knowledge  of  him,  which  extended  over 
upwards  of  thirty  years.  He  took  his  food,  however,  like  a 
ruminating  animal,  and  had  never  been  free  from  this  rumi- 
nating tendency,  as  far  as  he  could  remember,  so  that  it  was 
believed  to  be  congenital,  especially  as  post-mortem  examina- 
tion showed  no  trace  of  any  diseased  action.  He  always 
brought  up  a  portion  of  every  meal  he  took,  and  could  not 
swallow  solid  food  without  washing  down  each  mouthful  with 
fluid.  At  the  same  time,  he  always  persisted  in  saying  that 
he  did  not  vomit  his  food,  but  coughed  it  up,  and  that  he  had 
never  been  sick  in  his  life.  A  bougie  could  be  passed,  but 
it  was  always  followed  by  his  coughing  up  more  or  less  of 
the  solid  or  liquid  food  taken  within  the  last  few  hours.  On 
examination,  the  upper  part  of  the  oesophagus  was  found  enor- 
mously dilated,  measuring  six  and  a  half  inches  in  circum- 
ference in  its  undistended  state,  and  was  of  nearly  uniform  size 
throughout.  Towards  the  stomach,  however,  it  suddenly  con- 
tracted, and  here  the  tube  was  as  much  below  the  natural  size 
as  in  other  parts  it  was  above  it.  The  little  finger  could  just 
be  squeezed  through  into  the  stomach.  But  there  was  no  thick- 
ening, and  no  trace  of  cicatrization  as  the  result  of  disease." 

A  similar  condition  of  things  is  sometimes  attendant  upon 
simple  stricture  of  the  oesophagus,  the  result  of  the  inflamma- 
tory process,  without  the  production  of  pseudoplastic  deposit. 
The  inflammation  giving  rise  to  this  condition  may  have  impli- 
cated only  the  submucous  connective  tissue,  or  it  may  have 
affected  all  the  coats  of  the  oesophagus. 

Sometimes  the  immediate  cause  of  the  stricture  is  unknown, 
and  it  is  therefore  referred  to  a  spontaneous  origin.  Most  fre- 
quently the  strictui-e  results  from  tlie  inflammation  following 
mechanical  injury,  or  scalds  received  in  swallowing  hot  fluids  or 
caustic  substances.  The  most  common  seat  of  this  form  of  stric- 
ture is  at  the  upper  part  of  the  oesophagus,  the  narrowest  portion 
of  the  tube  in  its  normal  condition,  or  it  may  exist  at  the 
lowest  portion  of  the  pharynx,  just  behind  the  cricoid  cartilage 


STEICTUEE    OF   THE    (ESOPHAGUS.  217 

These  are  the  portions  most  accessible  to  mechanical  injury, 
bm-ns,  and  scalds.  Occasionally  the  stricture  is  the  result  of 
acute  or  chronic  inflammation,  of  spontaneous  origin.  It  is 
also  produced  by  the  existence  of  malignant  disease. 

The  stricture  is  usually  due  to  disease  involving  the  mucous 
membrane  and  submucous  connective  tissue,  though  sometimes 
involving  the  muscular  portion  of  the  tube  also.  In  cases  which 
are  not  cancerous,  the  diminution  of  the  calibre  of  the  tube  is 
usually  due  to  submucous  fibrinous  deposit,  and  to  thickening 
of  the  mucous  membrane.  This  diminution  may  be  so  great 
as  to  amount  to  almost  complete  occlusion.  The  seat  of  the 
stricture  is  usually  just  behind  the  lower  portion  of  the  larynx, 
or  just  below  it ;  but  it  may  occur  lower  down,  and  has  been 
known  to  take  place  within  three  or  four  inches  of  the  cardiac 
orifice  of  the  stomach.  Most  frequently  the  stricture  is  single, 
but  sometimes  there  are  two  or  three  of  them.  In  a  case  re- 
cently under  the  author's  care,  there  were  two  strictures,  one  just 
behind  the  lower  portion  of  the  larynx,  which  could  be  readily 
passed  with  a  moderately  large  bougie,  and  another,  apparently 
two  inches  below  it,  which  could  be  passed  only  by  means  of 
a  rat-tailed  bougie.  Most  of  the  cases  met  with  occur  in  early 
adult  life,  but  they  may  be  encountered  at  any  age.  Males 
appear  to  suffer  more  frequently  than  females. 

The  diagnosis  of  stricture  of  the  oesophagus  is  usually  sufli- 
ciently  easy.  The  patient  will  complain  of  more  or  less  difii- 
culty  of  deglutition,  which  in  severe  cases  may  amount  to  inability 
to  swallow ;  or  rather  of  an  impediment  or  obstacle  to  the  com- 
pletion of  the  act  of  deglutition.  This  is  sometimes  attended 
by  spasm,  regurgitation  of  food,  oppression  in  the  respiratory 
organs,  pain  in  the  parts,  and  more  or  less  nervous  distress. 
There  will  be  more  or  less  general  ill-health  from  insufiicient 
nourishment;  and  sometimes  pain,  more  or  less  severe,  w^ill 
be  complained  of  in  the  region  of  the  sternum,  stomach,  or 
cervical  vertebrae.  It  has  been  proposed  by  Dr.  Hamburger  ^ 
to  apply  auscultation  of  the  ossophagus  to  the  diagnosis  of  this 
and  other  diseases  of  the  tube.     The  fact  being  determined  that 

1  Medizin.  JaJiri.  xv.  11.    1868.     Qaz.  Hebd.  1868,  50,  p.  793. 


218  SPECIAL    AFFECTIOlSrS    OF   THE    (ESOPHAGUS. 

the  impaired  deglutition  is  not  due  to  paralysis,  to  abscess  of 
the  pharynx  or  oesophagus,  or  to  tumor,  the  suspicion  of  stric- 
ture arises ;  and  the  diagnosis  is  confirmed  or  disproved  by  the 
passage  into  the  stomach  of  gum-elastic  bougies,  or  oesophageal 
probes,  consisting  of  olive-shaped  masses  of  ivory  of  different 
sizes,  and  affixed  to  stout  whalebone  rods.  These  instruments  are 
to  be  carried  through  the  stricture  if  possible,  and  the  length  of 
the  constriction  is  judged  of  by  the  distance  along  which  resist- 
ance to  the  passage  of  the  instrument  is  felt ;  the  diameter  of 
the  stricture,  by  the  size  of  the  largest  instrument  wliich  can 
be  employed  ;  and  its  consistence,  by  the  amount  of  resistance 
offered  to  the  passage  of  the  exploring  instrument.  The  instru- 
ment, after  passing  a  stricture,  should  always  be  carried  down 
into  the  stomach,  in  order  to  ascertain  whether  there  be  any 
more  strictures  further  clown  the  oesophagus.  Great  care  is 
necessary  in  the  passage  of  these  instruments,  on  account  of  the 
probable  existence  of  a  pouched  condition  of  the  tube  immediately 
above  the  seat  of  stricture,  into  which  the  instrument  may  glide, 
and  through  which  it  may  be  thrust  by  the  employment  of  an 
undue  amount  of  muscular  force. 

In  cases  where  the  stricture  is  quite  small,  and  pouched  at  its 
side,  Dr.  J.  Mason  Warren  recommends  the  use  of  a  conical 
wax  bougie  Avith  the  tip  bent  forwards,  as  more  likely  to  pass 
the  stricture  than  a  straight  bougie,  which  would  be  apt  to  be- 
come caught  in  the  sac. 

The  treatment  of  stricture  of  the  oesoj)hagus  resolves  itself 
into  attention  to  the  general  health,  and  mechanical  or  opera- 
tive measures  for  the  removal  of  the  constriction. 

Where  there  is  cancerous  disease,  the  employment  of  local 
measures  for  relief  of  the  constriction  is,  in  the  main,  unjustifi- 
able, because  they  usually  produce  injury  which  may  be  serious 
in  character. 

The  local  treatment  consists  in  the  mechanical  dilatation  of 
the  stricture  by  the  repeated  passage  of  bougies,  or  oesophageal 
probangs  of  larger  and  larger  size,  or  of  metallic  tubes  which,  by 
mechanical  arrangements  externally,  can  be  gradually  dilated 
after  their  introduction.  Fig.  43  represents  a  very  common  and 
iiseful  form  of  dilator  for  stricture  of  the  oesophagus.     It  is 


STRICTURE    OF   THE    (ESOPHAGUS. 


219 


Fig.  43. 


composed  of  ivory  olives  attached  to  a  flexible  whalebone  rod, 
a  number  of  which  instrmnents  of  graduated  size  are  necessary 
for  the  treatment  of  the  affection. 

The  bougie  or  dilator  is  employed  every  day, 
every  other  day,  or  at  more  lengthened  intervals, 
according  to  the  tolerance  of  the  parts  and  the 
progress  of  the  case ;  being  retained  several 
minutes  at  each  introduction,  and  followed  by  the 
mere  passage,  in  and  out,  of  a  larger  instrument 
shortly  after  the  withdrawal  of  the  first  one.  This 
method  is  continued,  if  applicable,  until  it  is 
pretty  certain  that  nothing  further  is  to  be  gained 
in  this  way,  when  the  patient  may  be  dismissed, 
with  instructions  to  continue  the  passage  of  the 
instrument  once  a  week  or  once  a  fortnight,  to 
prevent  or  retard  the  recurrence  of  the  constric- 
tion, a  condition  which  is  very  likely  to  take  place. 

Forcible  dilatation,  by  mechanical  separation 
of  the  sides  of  a  double  metallic  sound,  has  some- 
times been  employed  with  success  ;  but  it  is  an 
ojDeration  which  may  prove  injurious,  and  is  to 
be  undertaken  with  great  care.  liesort  is  also  oc- 
casionall}'  made  to  a  combined  method  of  gradual 
and  forcible  dilatation,  consisting  in  passing  a 
thin  rubber  tube  along  the  stricture  by  means  of 
a  firm  conductor,  and  then  pouring  water  or  quick- 
silver into  the  tube,  to  dilate  the  distensible  por- 
tion within  the  grasp  of  the  stricture. 

Attempts  are  sometimes  made  to  destroy  the  cicatricial  tissue 
by  means  of  caustics  carried  to  the  parts  in  a  protected  tube,  so 
as  to  avoid  contact  with  the  sound  tissues.  This  method  has 
proved  successful  in  a  number  of  instances,  but  requires  great 
caution  in  selecting  cases  suitable  for  it. 

Division  of  the  stricture  has  been  performed  by  means  of  a 
concealed  lance  at  the  extremity  of  a  metallic  tube,  the  knife 
being  projected  when  the  stricture  is  felt,  and  then  carried 
through  it  and  retracted  as  soon  as  the  want  of  resistance  shows 
the  stricture  to  have  been  passed.     Dilatation  is  then  kept  up 


CEsophageal  Dila- 
tors for  Stricture. 


220  SPECIAL    AFPEOTIONS    OF     THE    (ESOPHAGUS. 

by  means  of   cesopliageal  tubes  and  bougies  frequently  intro- 
duced. 

CEsopbagotomy  bas  occasionally  been  practised  in  stricture  of 
tlie  oesopbagus,  but  tbe  results  bave  not  been  successful  as  to 
cure. 

Tbe  cure  of  a  stricture  usually  requires  Tery  protracted 
treatment,  Tarying  from  six  to  eigbteen  montbs  on  tbe  average. 
Many  cases  are  altogetber  insusceptiljle  of  treatment,  and  ter- 
minate fatally  in  a  few  montbs  or  a  few  years. 

In  tins  slow  way  tbe  celebrated  Englisb  pbysiologist,  Marsball 
Hall,  fell  a  victim  to  a  stricture  of  tbe  03sopbagus,  witb  ulcera- 
tion of  a  dilated  sac  of  tbe  pbarynx  and  oesopbagus  aboxe  tbe 
seat  of  stricture.  Post-mortem  examination  revealed  tbe  fact 
tbat  tbe  stricture  was  not  very  great,  but  tbat  a  fold  of  mucous 
membrane  at  its  upper  portion,  and  pointing  upwards,  formed 
a  sort  of  valve  wbicb  prevented  tbe  passage  of  food,  tbougb 
tbere  was  space  enougb,  as  found  after  deatb,  to  pass  tbe  finger 
tbrougb  tbe  stricture  from  below  upwards. 

Professor  Billrotb,  of  Yienna,  bas  suggested'  tbe  excision  of 
a  portion  of  tbe  oesopbagus  in  cases  of  carcinomatous  disease, 
being  disposed  to  consider  favorably  of  tbe  operation  in  conse- 
quence of  tbe  success  wbicb  so  frequently  attends  tbe  operation 
of  oesopbagotomy  for  foreign  body,  and  from  tbe  fact  tbat,  as  a 
rule,  cancer  of  tbe  oesopbagus  remains  confined  to  its  original 
locality,  and  does  not  extend  to  tbe  lympbatic  glands.  From 
some  experiments  made  by  bim  upon  tbe  dog,  be  is  inclined  to 
regard  tbe  operation  as  bolding  out  a  reasonable  bope  of  success. 
Nourisbment  could  be  maintained  tbrougb  tbe  wound  at  first, 
and  afterwards,  as  cicatrization  took  ]3lace,  tbrougb  tbe  montb, 
tbe  stomacb  tube  being  employed  until  its  use  becomes  no 
longer  necessary  ;  tbis  being  tbe  ]3lan  employed  in  tbe  experi- 
ments alluded  to. 

In  one  of  bis  successful  experiments  upon  tbe  dog,  be  re- 
moved an  entire  section  of  tbe  oesopbagus,  an  incb  and  a  balf  in 
lengtb ;  and  wben  tbe  animal  was  killed,  some  time  after  re- 
covery, it  was  found  tbat  tbe  cicatrix  was  very  narrow,  bardly 


Ardliiv  fur  KUmsche  CJiimrgie.     Bd.  xii.,  part  1,  1871,  p.  65. 


SPASM    OF    THE    (ESOPHAGrS.  221 

half  a  line  in  breadtli.  Billroth  is  of  opinion  that  operations  of 
this  kind  onght  to  be  as  successful  as  the  parallel  operations  of 
external  urethrotomy  in  cases  of  loss  of  substance  of  the  urethra 
from  ulceration  or  gangrene,  operations  which  are  followed  by 
perfect  restoration  of  function. 

The  resulting  cicatricial  stricture  would  be  apt,  in  the  one 
case  as  in  the  other,  to  yield  to  systematic  dilatation. 

A  constriction  of  the  oesophagus  is  sometimes  produced 
in  consequence  of  the  pressure  of  a  cancerous  or  other  tumor 
on  the  exterior  of  the  tube.  Such  cases  sometimes  occur  in 
connection  with  goitrous  tumors  which  have  extended  down- 
wards and  backwards.  These  cases  must  be  carefully  differ- 
entiated from  stricture  of  the  oesophagus  the  result  of  disease 
in  the  tube  itself,  for  they  are  not  amenable  to  local  treatment. 
A  few  cases  have  been  recorded  in  which  more  or  less  tem- 
porary amelioration  has  followed  the  careful  introduction  of 
tubes  for  the  purpose  of  supplying  nourishment ;  an  enlarge- 
ment of  the  available  calibre  of  the  oesophagus  having  resulted. 

SPASM    OF    THE   (ESOPHAGUS. 

A  spasmodic  constriction  of  the  oesophagus  is  not  unfre- 
quently  met  with,  and  is  known  as  spasmodic  stricture  of  the 
oesophagus.  The  inability  to  swallow  usually  occurs  suddenly 
and  unexpectedly,  and  is  often  attended  with  pain  and  a  sense 
of  constriction  of  the  part.  It  is  usually  met  with  in  individuals 
subject  to  affections  of  the  intestinal  canal,  of  the  spinal  column, 
or  other  organs,  and  is  often  one  of  the  manifestations  of  that 
condition  which  we  denominate  hysteria.  Though  occurring 
most  frequently  in  nervous  females,  it  affects  males  also.  It 
has  been  noticed  at  all  ages. 

Spasm  sometimes  exists  for  years.  The  nature  of  the  affec- 
tion is  diagnosed  by  the  passage  of  an  oesophageal  bougie,  an 
.operation  which  often  cures  the  spasm  at  once.  Where  this 
does  not  happen,  and  there  is  no  doubt  as  to  the  diagnosis,  the 
passage  of  the  sponge  probang  saturated  with  a  solution  of 
nitrate  of  silver,  and  repeated  every  few  days,  is  often  adequate 


222  SPECIAL    AFFECTIONS    OF   THE    (ESOPHAGUS. 

to  relief.  Sometimes  the  constriction  ceases  as  suddenly  and 
as  miexpectedly  as  it  commenced. 

The  general  health  is  to  be  attended  to,  tonics  being  usually 
called  for.  The  internal  administration  of  antispasmodics,  and 
the  application  externally  along  the  spine  of  a  mustard  poultice, 
a  blister,  or  a  stimulating  liniment,  will  also  often  be  indi- 
cated. 

The  23assage  of  the  electric  current,  the  positive  pole  being 
applied  to  the  seat  of  spasm  by  means  of  the  oesophageal  elec- 
trode, will  often  promptly  overcome  the  constriction  ;  the  source 
of  the  electricity,  in  the  main,  being  a  matter  of  indifference. 

DILATATION    OF    THE    (ESOPHAGrS. 

An  abnormal  dilatation  of  the  oesophagus  is  sometimes  met 
with,  chiefly  as  a  pathological  curiosity.  Most  of  the  subjects 
of  this  affection  had  been  addicted  during  lite  to  a  species  of 
rumination. 

M.  Raymond'  reports  a  case  in  which  the  abnormal  dilatation 
took  place  between  the  lobes  of  the  lungs,  from  the  base  of  the 
heart  to  the  cardia. 

Prof.  Luschka  has  reported^  a  very  remarkable  case  of  this 
kind  in  a  woman  some  fifty  years  of  age,  who,  from  her  fifteenth 
year,  had  possessed  the  faculty  of  voluntary  regurgitation  of 
food,  without  effort  and  without  pain.  Towards  the  close  of 
her  life  she  suffered  with  rheumatism,  hemorrhagic  erosions  of 
the  stomach  and  oesophagus,  leading  to  the  vomiting  of  coagu- 
lated black  blood,  from  the  loss  of  which,  with  the  coexistent  can- 
cerous degeneration  of  several  lymphatic  glands,  a  condition  of 
debility  was  produced  which  terminated  fatally  by  oedema  of 
the  lungs.  A  post-mortem  examination  revealed  the  existence  of 
an  enormous  dilatation  of  the  oesophagus  (Fig.  44),  nearly 
equalling  in  bulk  the  capacity  of  the  stomach.  There  was 
no  constriction  of  the  cardiac  portion  below  it,  as  in  the  cases 
reported  by  Ilokitansky  and  others.      The  dilated   oesophagus 


1   Gaz.  Mkl.     Paris,  1809.     No.  7,  p.  91. 

*  Virchow's  Archid  far  Anat.,  &c.,  March,  1868,  p.  473. 


DILATATION    OF    THE    (ESOPHAGUS. 


223 


■was  46  centimetres  in  length  instead  of  29  centimetres,  the 
normal  length.  Hence  it  is  evident  that  it  mnst  have  occupied 
a  cm-vilinear  position  during  life.      At  the  point  of  greatest 


Fig.  44. 


Enormous  dilatation  of  oesophagus  1-6  natural  size  (Luachka). 

A  larynx. 

B  thyroid  gland. 

C  trachea.' 

D  oesophagus. 

E  stomach. 


224  SPECIAL    AFFECTIONS    OF    THE    (ESOPHAGUS. 

enlargement  it  equalled  the  size  of  the  arm  of  a  muscular  man, 
being  30  centimetres  in  circumference ;  the  medium  circum- 
ference being  normally  but  7^  centimetres,  A  sort  of  spindle 
shape  was  given  to  the  enlargement  by  a  slight  constriction  at 
the  border  of  the  upper  and  middle  thirds,  where  it  occurs  in 
the  normal  oesophagus.  The  muscular  layer  was  hypertrophied, 
and  the  mucous  membrane  gave  evidence  of  the  existence  of 
intense  catarrhal  inflammation,  with  the  existence  of  the  hem- 
orrhagic erosions  that  were  suspected  during  life. 

PxlEALTSIS    OF    THE  PHARYNX   AND    (ESOPHAGUS. 

Paralysis  of  the  muscular  fibres  of  the  pharynx  and  oesopha- 
gus is  sometimes  met  with.  If  the  dysphagia  indicative  of  this 
condition  occurs  at  the  initial  moment  of  deglutition,  the  trou- 
ble is  likely  to  be  situated  in  the  pharynx ;  if  at  a  later  moment, 
it  may  be  in  the  oesophagus.  It  sometimes  occurs  in  the  course 
of  acute  disease,  as  one  of  the  precursors  of  death.  Liquids  are 
sometimes  swallowed  with  great  difhculty,  and  the  attempt  at 
deglutition  is  accompanied  by  contortions  of  the  head  and  neck 
to  assist  their  passage.  Not  unfrequently,  the  liquid  passes  into 
the  air  passages.  In  chronic  diseases,  in  which  the  brain  and 
spinal  cord  become  affected,  the  power  of  swallowing  is  some- 
times lost  a  long  time  before  death,  the  approach  of  which 
may  be  retarded  by  the  use  of  the  stomach  tube  for  the  injec- 
tion of  nutriment. 

Sometimes  the  paralysis  occurs  in  the  wake  of  diseases,  such 
as  diphtheria,  after  convalescence  has  been  established ;  and 
sometimes  it  appears  to  occur  as  an  independent  affection. 

The  author  recently  encoimtered  a  case  of  inability  to  swal- 
low solids  from  paralysis  of  the  constrictor  muscles  of  the  pha- 
rynx, the  result  of  sun-stroke.  The  affection  continued  for 
several  months,  during  the  last  three  of  which  the  patient  was 
under  the  author's  personal  care.  Faradization  of  the  constric- 
tors, repeated  every  two  or  three  days,  finally  resulted  in  a  cure. 
The  negative  pole  was  placed  upon  the  muscles  of  the  pharynx 
and  moved  from  one  to  the  other,  the  positive  pole  being  held 
in  the  hand  or  placed  at  some  indifferent  portion  of  the  body. 

The  local  employment  of  electricity  in  some  of  its  forms,  and 


GLOSSO-PHAEYNGEAL    PAEALYSIS.  225 

the  internal  administration  of  a  salt  of  strychnia,  or  its  hypo- 
dermic use,  would  seem,  with  the  aid  of  tonics  and  nourishing 
broths,  to  he  the  most  appropriate  treatment  for  cases  of  this 
nature. 

If  the  oesojDhagus  be  paralyzed,  there  may  be  danger  in  using 
an  oesophageal  electrode,  as  shown  by  Duchenne,  for  fear  of  un- 
duly exciting  the  pneumogastric  nerve,  and  thereby  inducing 
syncope. 

A  case  of  paralysis  of  the  oesophagus  coming  on  during  preg- 
nancy, and  returning  during  a  second  pregnancy,  occurred  un- 
der the  care  of  M.  Demarqnay,^  in  which  notable  amelioration 
followed  a  treatment  by  electro-puncture. 

GLOSSO-PHAUYNGEAX.   PARALYSIS. 

A  certain  variety  of  progressive  general  paralysis,  almost  al- 
ways fatal,  makes  its  first  appearance  as  a  local  involvement  of 
one  or  more  of  the  muscular  factors  concerned  in  the  perform- 
ance of  the  functions  of  mastication,  deglutition,  speech,  and 
respiration. 

It  has  been  called  glosso-laryngeal  paralysis,  glosso-pharyn- 
geal  paralysis,  labio-glosso-laryngeal  paralysis,  &c.  To  desig- 
nate most  of  the  main  factors  of  the  malady  in  one  appellation 
we  should  require  a  name  as  long  as  labio-glosso-pharyngo- 
laryngeal  paralysis ;  and  then  we  would  not  have  indicated  its 
connection  with  the  palate  and  the  cheeks. 

Attention  was  directed  to  this  special  affection  by  Prof. 
Trousseau  in  1844;  but  marked  professional  notice  was  first 
prominently  called  to  it  by  Duchenne  (of  Boulogne)  in  1860,  and 
subsequently  again  (1864)  by  Trousseau,  and  by  OUivier ;  since 
which  time  it  has  formed  the  theme  of  many  valuable  articles 
in  the  medical  journals  of  Europe  and  America. 

Recently,  Duchenne  has  again  called  marked  attention  to  the 
subject"  in  an  elaborate  essay  upon  the  structure  and  morpho- 
logy of  the  medulla  oblongata. 

1  Bull.  Gen.  de  Thercqx,  Jtdy  30,  1869,  p.  82. 

^  E,echerches  incono-photographiques  sur  la  morphologie  et  sur  la  structure 
intime  du  bulbe  humain,  leur  application  a  1' etude  anatomo-pathologique  de  la 
paralysie  glosso-labio-laryngee. — Arch.  Gen.  deMed.,  May,  1870,  p.  bod^et  seq. 

15 


226  SPECIAL    AFFECTIONS    OF    THE    CESOPHAGUS. 

The  affection  has  been  more  frequently  observed  in  males 
than  in  females ;  and,  as  a  rale,  in  subjects  of  over  fifty  years  of 
affe.  Some  observers  have  never  seen  it  before  the  ao-e  of  f ortv. 
Two  of  the  author's  cases,  one  subjected  to  treatment,  and  the 
other  not,  were  under  thirty  years  of  age.  There  are  one  or 
two  instances  on  record  in  which  the  disease,  or  an  affection 
simulating  it  to  a  remarkable  degree,  began  during  an  access  of 
febrile  disease.  Usually,  some  mental  trouble,  such  as  loss  of 
•property,  of  members  of  one's  family,  etc.,  appears  to  be  the 
excitino-  cause.  In  the  case  of  the  youngest  subject  which  the 
author  has  seen,  the  cause  seemed  to  be  over-study  for  honors 
at  college. 

The  affection  usually  begins  with  a  paralysis  of  the  orbicularis 
oris  and  adjacent  muscles,  gradually  progressing,  until  finally  the 
patient  is  unable  to  pronounce  the  consonants  and  vowels  requir- 
ing the  use  of  the  lips,  such  as  o,  m,^,  b,f,  v,  and  in  a  little  while 
is  unable  to  blow  or  to  kiss.  As  the  disease  progresses  the  tongue 
becomes  involved,  and  then  the  palate,  the  pharynx,  the  cheeks, 
and  the  larvnx.  Sometimes  it  begins  in  the  tongue,  with  failure 
in  the  pronunciation  of  the  dentals,  etc.,  t,  d,  n,  th,  ch,  etc.,  and 
more  or  less  difficulty  in  controlling  the  alimentary  bolus. 
There  therefore  occurs  more  or  less  dysphagia,  gradually  pro- 
gressive ;  nasal  speech,  and  escape  of  drinks  from  the  nostrils ; 
inability  to  retain  the  saliva ;  and  aphonia.  At  a  further  stage 
of  the  affection  the  respiratory  muscles  become  affected ;  and 
finalN  in  some  instances,  tliere  ensues  paralysis  of  the  limbs. 
Sometimes  cerebellar  ataxia  follows  the  affection,  and  this  may 
take  place  even  several  months  after  satisfactory  relief  from  the 
orio-inal  affection.'  The  patient  gradually  shiks  a  prey  to 
debility  consequent  upon  inanition. 

The  pathological  observations  thus  far  made  show  this  affec- 
tion to  be  due  to  sclerosis  or  other  structural  lesion  of  the 
medulla  oblongata,  with  fatty  or  tuberculous  degeneration  of 
the  roots  of  the  nerves  distributed  to  the  parts  affected  by  the 
disease  •  or  sometimes  a  mere  atrophy,  a  fatty  degeneration  of 

'  Sdiiitzenberger :  Cas  de  paralysie  labio-glosso-pharyngienne  suivie  d'ataxie 
cerebelleuse.     Gaz.  Med.  de  Strasbourg,  1868,  p.  74. 


TUMOES    IN    THE    (ESOPHAGUS.  227 

the  muscular  fibres  of  the  parts  affected,  has  been  found  to 
exist,  though  this  does  not  constitute  an  essential  element  of  the 
lesion.  The  disease,  as  a  rule,  is  fatal.  A  few  cases  of  recovery 
or  of  retrogression,'  and  several  of  amelioration,  persisting  for  a 
long  time,''  are  on  record ;  and  in  these  it  must  be  inferred  that 
there  has  been  merely  a  congestion  at  the  roots  of  the  nerves, 
a  hemorrhage,  or  some  other  condition  preparatory  to  the  stage 
of  degeneration,  the  tendency  to  which  has  been  fortunately 
overcome. 

Counter-irritation  at  the  nape  of  the  neck,  iodide  of  potas- 
sium, or  its  equivalent,  internally,  and  local  faradization  of  the 
affected  muscles,  appear  to  be  the  chief  remedial  agents  relied 
upon  for  the  treatment  of  this  affection,  the  prognosis  being 
always  a  grave  one. 

TUMORS   IN   THE   (ESOPHAGUS. 

Tumors  of  the  oesophagus  are  not  of  frequent  occurrence.  Dr. 
J.  Mason  Warren  records '  a  curious  case  of  a  large  polyp  de- 
pending into  the  oesophagus,  and  attached  to  the  outside  of  the 
epiglottis.  The  patient,  a  gentleman  of  fifty-four  years  of  age, 
began  to  experience  a  soreness  of  the  throat  in  swallowing,  in 
1860,  and  some  ten  weeks  afterwards  was  able  to  force  into  his 
mouth  a  tumor  from  the  oesophagus.  This  gave  him  but  little 
inconvenience  for  six  years,  when  it  began  to  increase  rapidly, 
and  caused  much  trouble  in  deglutition.  He  ajDplied  to  Dr. 
Warren  some  three  weeks  after  the  appearance  of  these  trouble- 
some symptoms,  and  forced  into  his  moutli,  by  an  effort  of  r-egur- 
gitation,  a  large  white-looking  tumor  of  the  shape  and  size  of  a 
small  sausage.  It  resumed  its  situation  in  the  oesophagus  on  a 
slight  effort  of  the  patient.  The  finger  detected  its  origin  in 
the  neighborhood  of  the  ej)iglottis ;  and  a  laryngoscopic  exami- 
nation showed  this  origin  to  be  by  a  broad  base,  commencing 
low  down  on  the  left  side  of  the  epiglottis,  which  it  dragged 

1  La  Tribune  Medimle^  1868,  p.  340  ;  Alex.  Smith,  Med.  Times  and  Qaz.., 
1871,  April  22,  p.  464;  the  author,  The  Medical  Record,  vol.  iv.  p.  291. 

2  Herard  :   Gaz.  Hebd.,  1868,  p.  182. 

°  Surgical  Observations.     Boston,  1866,  p.  IIG, 


228  SPECIAL    AFFECTIO]S"S    OF    THE    (ESOPHAGUS. 

down  and  over  to  the  same  side,  whence,  by  a  ribbon-like 
pedicle,  it  extended  into  the  oesophagus. 

Being  brought  up  into  the  mouth,  it  was  transfixed  by  a 
curved  needle  armed  with  a  long  thread.  As  it  bled  freely,  it 
was  tied  by  a  strong  ligature,  as  near  the  base  as  jjossible,  and 
was  then  cut  off  in  front  with  Simpson's  long-curved  scissors. 

The  portion  removed  was  about  three  inches  in  length  and 
two  inches  in  circumference.  It  was  of  a  fibrous  character. 
Gentle  drawing  upon  the  ligatures  for  two  or  three  days  in- 
duced the  spontaneous  expulsion  of  the  pedicle. 

Dr.  Gibb  ^  relates  a  case  of  large,  pendulous,  fatty  tumor  in 
this  situation,  in  a  man  of  eighty  years  of  age,  who  had  had 
throat  symptoms  for  twelve  years,  and  who  died  suddenly  while 
smoking. 

Four  years  before  his  death,  during  an  act  of  vomiting,  a 
large  mass  protruded,  which  he  was  obliged  to  return  as  soon 
as  possible,  to  prevent  suffocation. 

A  large,  pendulous,  fatty  tumor  was  found  filling  the 
pharynx,  and  extending  into  the  oesophagus  to  the  extent  of 
nine  inches.  It  was  attached  by  an  envelope  of  mucous  mem- 
brane and  fibrous  tissue  to  the  left  side  of  the  epiglottis,  which 
it  dragged  downwards  and  to  the  left  side  so  as  to  prevent  per- 
fect closure  of  the  larynx,  and  it  was  also  connected  with  the 
upper  part  of  the  pharynx. 

Middeldorpf  '^  narrates  the  case  of  a  man  of  twenty-six  years 
of  age  from  whom,  in  January,  1853,  he  removed  an  oesopha- 
geal polyp,  after  having  encircled  its  base,  near  the  root  of  the 
tongue,  by  a  strong  silken  ligature.  The  excision  was  practised 
about  three-fourths  of  an  inch  in  front  of  the  ligatm-e.  The 
excised  portion  was  three  inches  in  length  and  an  inch  and  a 
half  in  diameter,  and  weighed,  after  a  great  deal  of  blood  had 
flowed  from  it,  one  ounce  and  three  drachms.  Examined  under 
the  microscope,  it  proved  to  be  a  fibroid  tumor  with  numerous 
vessels  and  pajDillse.  The  ligature  came  away  with  the  remains 
of  the  polyp  upon  the  twenty-first  day.  Five  years  after  the 
operation  the  patient  was  still  well. 

1  On  the  Throat  and  Windpipe.     2d  ed.,  p.  371. 
«  Schmidt's  Jahrb.  99,  p.  131. 


WOLWDS    OF    THE    (ESOPHAGUS.  229 

In  Middeldorpf  s  case,  and  in  that  of  Warren,  the  ligature 
was  secured  to  the  ear. 

Professor  Rokitansky,  Dallas,  Middeldorj)f,  and  others  have 
also  recorded  cases  in  which  the  length  of  the  tnnior  exceeded 
six  inches. 

WOUNDS    OF    THE    (ESOPHAGUS. 

The  oesophagus  is  not  infrequently  wounded  in  connection 
with  injuries  inflicted  upon  the  larynx  and  trachea  ;  but  cases  of 
wounds  limited  to  the  oesophagus  are  rare,  and  are  said  to  be 
usually  the  result  of  gun-shot  wounds  from  small  bullets,  or  to 
be  due  to  puncture  bythe  point  of  a  knife,  sword,  or  dagger. 
Ilourteloup  ^  has  only  been  able  to  collect  four  cases  of  incised 
wounds  of  the  oesophagus:  those  of  Boyer,  Larrey,  and  Du- 
puytren. 

When  occurring  in  suicides,  there  has  usually  been  fatal 
hemorrhage  from  division  of  the  great  vessels  of  the  neck. 
Attempts  at  exploration  of  the  oesophagus  by  means  of  the 
sound  have  been  followed  by  laceration  of  this  tube,  as  has  also 
the  incautious  use  of  improper  instruments  in  attempts  at  the 
extraction  of  foreign  bodies.  It  has  also  been  wounded  occa- 
sionally in  making  the  incision  for  tracheotomy  ;  and  a  case  is 
on  record  in  which  the  tracheotomy  tube  was  actually  passed 
into  the  oesophagus. 

M.  de  Guise,  a  surgeon  of  Charenton,  has  reported  (Compte- 
rendu  de  la  Soc.  de  Chir.)  the  case  of  an  insane  person  who 
introduced  into  the  oesophagus  the  handle  of  a  little  explosive 
toy,  which  lacerated  the  organ  a  little  below  the  pharynx, 
and  then  fi-actured  the  fourth  rib  at  the  vertebral  articulation.^ 

Lacerated  wounds  of  the  oesophagus  are  sometimes  produced 
during  an  act  of  vomiting.  Several  cases  of  rupture  from  this 
cause  are  on  record,  the  subjects  of  the  accident  usually  being 
persons  of  intemperate  habits.  The  injury  is  almost  necessarily 
fatal,  for  there  is  no  external  outlet  for  the  matters  which 
escape  from  the  oesophagus. 


'  Plaies  du  Larynx,  de  la  trachee,  et  de  I'oesophage.     Paris,  1869,  p.  19. 
^  Hourteloup,  op.  cit.  p.  24. 


230  SPECIAL    AFFECTIONS    OF    THE    (ESOPHAGUS. 

Rupture  of  the  CEsophagus. — Iloiirteloup^  reproduces 
the  following  case  of  Boerhaave  (Yan  Swieten's  Commenta- 
ries, vol.  ii.,  p.  102.     Edinburgh,  1Y86) : 

A  Baron  Yassenaer  was  accustomed  to  relieve  himself  by 
vomiting  whenever  he  had  committed  an  excess  at  table,  which 
occurred  frequently.  One  evening,  after  dining  copiously,  he 
endeavored  to  assist  the  emesis  by  an  infusion  of  chardon  benit, 
and  vomited,  making  extraordinary  efforts.  Suddenly  he  was 
seized  with  a  very  acute  pain,  which  was  increased  by  whatever 
he  attempted  to  swallow.  Death  occurred  after  eighteen  hours 
of  intense  suffering.  The  lungs  were  found  swimming  in  a 
fluid  similar  to  that  found  in  the  stomach.  There  was  a  trans- 
versal rupture  of  the  oesophagus,  three  fingers'  breadth,  above 
the  diaphragm.  The  most  careful  examination  discovered  no 
trace  of  ulcer  or  erosion  of  the  ruptured  organ. 

Dr.  J.  J.  Charles,  of  Belfast,  records  °  a  case  of  a  man,  setat. 
35,  of  intemperate  habits,  who,  while  vomiting,  felt  something 
give  way  in  his  inside,  and  died  about  seven  and  a  half  hours 
afterwards.  A  longitudinal  fissure  was  found,  penetrating  all 
the  coats  of  the  oesophagus,  on  the  left  side,  near  the  posterior 
wall,  reaching  from  immediately  below  the  cardiac  orifice  of  the 
stomach  upwards  for  an  inch  and  a  half,  but  extending  farther 
in  the  mucous  membrane  than  in  the  muscular  and  fibrous  coats. 

Dr.  Charles,  Avho  likewise  mentions  Boerhaave's  and  some 
others,  cites  a  case  reported  by  Mr.  Dry  den, ^  a  surgeon  of  Ja- 
maica, in  which  an  officer,  after  inebriation,  was  seized  with 
nausea  and  an  inclination  to  vomit,  to  promote  which  he  drank 
some  w^arm  water ;  and  during  the  straining  which  it  produced 
he  felt  something  give  way  internally,  which  gave  him  the  sen- 
sation as  if  he  had  received  an  injection  of  some  liquid  matter 
into  the  cavity  of  the  thorax. 

Emphysema  of  the  neck  ensued.  The  patient  died  in  eight 
or  ten  hours.  A  longitudinal  laceration,  large  enough  to  admit 
the  fore  and  middle  fingers,  was  discovered  in  the  oesophagus, 
just  before  it  passes  through  the  diaphragm. 

'  Plaies  du  larynx,  de  la  trachee,  et  de  I'cesopliage.     Page  23. 
^  Duh.  Quart.  Jour.  Med.  Science.     November,  1870,  p.  311. 
^Medical  Gommentaries.,  Edinburgh.    Decade  2.    Vol.  iii.  1788. 


RUPTUEE    OF   THE    (ESOPHAGUS.  231 

About  a  gallon  of  a  mixture  of  wine,  water,  and  food  was 
contained  in  the  left  pleura  ;  and  nearly  two  quarts  of  the  same 
kind  of  Hi) id  in  the  right  pleura. 

Dr.  Monro,  Morbid  Anatomy^  1811,  p.  311,  mentions  a  simi- 
lar instance,  communicated  to  him  by  Dr.  Carmichael  Smyth. 
Other  references  are  given  by  Dr.  Charles,  which  may  be  con- 
sulted with  advantage  in  further  elucidation  of  the  subject. 

The  treatment  of  wounds  of  the  oesophagus  must  be  con- 
ducted on  general  principles,  suited  to  the  exigencies  of  the 
case.  Under  some  circumstances  the  opening  into  the  gut 
must  be  kept  patulous,  in  order  to  permit  the  injection  of  food 
into  the  stomach.  As  soon  as  there  is  evidence  that  cicatrization 
is  proceeding  favorably,  food  is  cautiously  administered  in  the 
natural  way,  care  being  taken  with  regard  to  its  quantity  and 
quality.  If  food  j)ass  out  of  the  wound,  nourishment  must  be 
maintained  by  the  rectum ;  and  thirst  allayed  by  moistening 
the  lips,  tongue,  and  gums  from  time  to  time,  and  by  periodi 
cal  sponging  of  the  body.  Great  precaution  is  necessary,  in  the 
return  to  an  ordinary  diet,  that  the  cicatrix  be  not  ruptured. 

There  is  no  evidence  to  show  that  wounds  of  the  oesophagus 
are  liable  to  be  followed  by  permanent  constriction  of  the  tube. 
Fistulous  openings  sometimes  remain  after  the  healing  of  a 
wound  in  the  oesophagus.  They  are  treated  by  the  local  appli- 
cation of  nitrate  of  silver  or  sulphate  of  copper,  and  are  said 
to  heal  promptly.  It  is  not  generally  considered  advisable  to 
make  an  attempt  to  close  them  by  plastic  operation,  as  is 
practised  in  cases  of  iistules  communicating  with  the  larynx  or 
trachea. 

Most  authors  are  opposed  to  the  use  of  sutures  in  cases  of 
wounds  of  the  oesophagus ;  but,  as  is  urged  by  Prof.  Gross, 
there  is  probably  too  much  temerity  shown  in  this  respect ;  for 
such  wounds  would  seem  to  call  for  treatment  similar  to  that 
adopted  for  wounds  of  the  intestines,  and  he  therefore  recom- 
inends  that  they  be  united  by  the  interrupted  suture,  both  ends 
of  which  should  be  cut  close  to  the  knot,  in  the  expectation 
that  the  thread  would  find  its  way  into  the  interior  of  the  tube 
and  be  discharged  with  the  contents  of  the  bowel. 


232  SPECIAL    ArrECTIO]N"^S    OF    THE    (ESOPHAGUS. 


FOEEIGlSr   BODIES    IN   THE   (ESOPHAGUS. 

Foreign  bodies  occasionally  lodge  in  tlie  lower  portion  of  the 
pharynx  and  in  the  oesophagus,  and  may  produce  death  from 
asph^'-xia  in  a  few  minutes,  from  compression  of  the  trachea. 
A  number  of  cases  of  this  kind  are  on  record  in  professional 
journals,  and  in  the  newsj)apers.  Tiie  occurrence  of  this  acci- 
dent has  sometimes  been  mistaken  for  a  stroke  of  apoplexy. 
The  foreign  body  usually  is  some  article  of  food — as  a  large 
morsel  of  meat,  a  piece  of  bone,  etc. ;  but  not  infrequently  is 
something  that  should  not  have  been  put  in  the  mouth  at  all — 
such  as  a  coin,  fish-hook,  j)in,  tack,  etc.  Human  parasites  some- 
times lodge  in  the  oesophagus  as  a  foreign  body.  A  case  of 
acute  delirium  from  this  cause  has  been  reported  by  Laurent. 
Lately,  since  the  wearing  of  false  teeth  has  become  so  common,' 
the  plate  is  sometimes  swallowed  during  sleep  and  becomes 
wedged  in  the  oesophagus  or  pharynx. 

The  accident  sometimes  occurs,  in  cases  of  stricture  of  the 
oesophagus,  fi-om  want  of  care  in  swallowing  morsels  of  food. 

The  point  of  lodgment  of  the  foreign  body  is  usually  the 
lower  portion  of  the  pharynx  or  the  up23er  portion  of  the  oeso- 
phagus ;  but  it  is  sometimes  much  more  deeply  situated,  oppo- 
site the  upper  portion  of  the  sternum,  or  about  the  region  of 
the  diaphragm.  A  not  infrequent  place  of  lodgement  is  in  the 
pyriform  sinus  formed  by  the  inner  wall  of  the  wing  of  the 
thyroid  cartilage  and  the  outer  wall  of  the  quadrangular  mem- 
brane of  tlie  pharynx. 

The  sjnnptoms  of  the  presence  of  a  foreign  body  in  the  oeso- 
phagus will  vary  with  the  nature  of  the  intruder  and  the  posi- 
tion it  occupies.  A  smooth  and  small  body  may  give  rise  to 
very  slight  symjDtoms — merely,  perhaps,  the  consciousness  of 
having  swallowed  it,  and  a  vague  sense  of  its  ]3resence  in  some 
particular  part  of  the  gullet.  A  larger  body  will  give  rise  to 
gagging  and  vomiting,  during  which  efforts  it  is  often  detached. 
A  pin  will  give  rise  to  a  sensation  of  pricking,  and  sometimes 
to  slight  hemorrhage.     Large  bodies  prevent  further  swallow- 

^  Ann.  Med.  Psi/c7t.,  Sept.  1807. 


FOEEIGN    BODIES    IN    THE    (ESOPHAGUS.  233 

ing  by  their  size,  and  sharp  ones  by  the  pain  which  the  effort 
produces.  If  the  body  is  large  or  irregular,  or  presses  upon  the 
trachea,  or  sticks  by  a  point  to  some  portion  of  the  larynx,  there 
will  be  more  or  less  pain  in  swallowing  or  in  breathing,  which 
will  be  apt  to  be  increased  on  pressure.  Cough,  spasm  of  the 
glottis,  hoarseness,  and  symptoms  of  an  inflammatory  character 
may  supervene,  and  sometimes  may  increase  to  such  an  extent 
as  to  be  very  serious.  The  only  certainty  of  diagnosis  rests  in 
exploration  with  the  finger  or  the  probe,  unless  the  foreign 
body  can  be  seen  with  the  larjmgoscopic  mirror  or  without  it. 

If  a  foreign  body  is  not  removed  from  the  oesophagus  it  may 
give  rise  to  inflammation  and  abscess,  and  produce  ulceration  of 
the  tissues  in  front  of  it.  Foreign  bodies  sometimes  make  their 
way  to  the  exterior  in  this  manner,  and  may  thus  give  rise  to 
the  formation  of  a  fistnle.  Or  the  foreign  body  may  ulcerate 
the  anterior  part  of  the  tube  and  enter  the  trachea,  producing 
death  from  suffocation  or  from  inflainmation  of  the  air-passage  ; 
or  it  may  result  in  the  formation  of  a  tracheo-ossophageal  fistule, 
and  thus  produce  irreparable  mischief.  A  singular  case  of  this 
kind  came  under  the  author's  notice  a  few  years  since.  He  was 
called  in  consultation  to  a  neighboring  city  to  examine  a  man 
with  chronic  hoarseness  of  several  months'  standing.  The  story 
was,  that  about  a  year,  or  rather  more,  previously,  the  patient 
had  swallowed,  during  his  sleep,  a  gold  plate  to  which  a  false 
tooth  was  attached.  The  physician  who  was  called  in  to  the 
case  felt  the  foreign  body  with  his  finger,  and,  failing  to  ex- 
tract it,  pushed  it  forcibly  into  the  stomach.  A  few  months 
later,  the  author  was  again  sent  for  on  account  of  a  new  set  of 
symptoms.  He  found  the  patient  feeble  and  in  bed,  unable  to 
eat  or  drink,  every  attempt  at  drinking  being  followed  by  ejec- 
tion of  the  fluid  in  a  paroxysm  of  spasmodic  cough.  Larjmgo- 
scopic  inspection  did  not  reveal  anything  more  than  the  general 
inflammatory  condition  recognized  at  the  previous  interview, 
except  that  there  was  a  profuse  secretion  of  pus.  The  cough 
and  ejection  did  not  follow  immediately  upon  the  act  of  swal- 
lowing, but  a  few  moments  after,  as  the  fluid  passed  down  the 
oesophagus.  An  opinion  was  therefore  given  that  a  fistulous 
connection  existed  between  the  oesophagus  and  trachea,  pro- 


234  SPECIAL    AFFECTI02s'S    OF    THE    (ESOPHAGUS. 

duced  hj  chronic  inflammation  following  a  wonnd  made  by  a 
shai^D  edge  of  the  plate,  in  the  effort  at  pushing  it  into  the 
stomach.  A  reqiiest  to  be  permitted  to  pass  the  stomach-tube 
was  not  acceded  to,  inasmuch  as  it  had  been  passed  into  the 
stomach  a  short  time  before,  by  the  physicians  in  attendance, 
without  encountering  any  obstruction,  though  pus  was  brought 
up  on  its  extremity,  the  passage  of  the  instrument  being  painful 
to  the  patient.  The  patient  was  nourished  for  nineteen  (?)  days 
by  the  rectum,  and  was  doing  well,  being  again  able  to  swallow 
with  very  little  difSculty,  when  he  one  day  ate  a  number  of 
apples  that  had  been  brought  into  his  room,  was  seized  with 
cholera  morbus,  and  died.  A  post-mortem  examination  was 
made,  and  the  gold-plate  was  found  lodged  in  the  CBsophagus 
opposite  the  bifurcation  of  the  trachea,  w^ith  a  communicating 
opening  between  the  two  tubes. 

The  treatment  of  a  foreign  body  in  the  oesophagus  consists  in 
its  prompt  dislodgement.  This  may  be  effected  in  various  ways 
according  to  the  nature  of  the  body,  and  the  emergency  or 
peculiarity  of  the  case.  If  the  foreign  body  can  be  seen  or  felt, 
it  can  often  be  removed  by  the  finger,  or  by  means  of  straight 
or  slightly  curved  forcej)s,  such  as  are  used  in  torsion  of  nasal 
polyps.  If  it  is  lodged  in  one  of  the  pyramidal  sinuses,  it  can 
be  seen  with  the  laryngosco23e  and  removed  with  the  laryngeal 
forceps,  or  be  dislodged  by  a  blunt  hook,  when  it  will  be  spit  up. 
A  long  finger  will  often  be  able  to  hook  out  a  foreign  body 
from  this  position.  In  cases  of  the  swallowing  of  such  articles 
as  fish-bones,  needles  and  pins,  which  often  lodge  in  this  situa- 
tion, care  must  be  taken  not  to  mistake  for  the  foreign  body 
the  tense  pharyngo-epiglottic  ligament,  which  gives  to  the  un- 
trained finger  much  the  sensation  of  a  firm  and  slender  foreign 
body.  This  mistake  has  been  made  by  the  author,  and  doubt- 
less by  many  others,  though  not  mentioned  in  the  books.  Under 
a  misapprehension  of  this  kind  the  forceps  may  be  employed 
to  pull  out  some  of  the  normal  tissues.  A  laryugoscopic  inspec- 
tion will  usually  set  any  doubt  at  rest ;  and  when  this  cannot  be 
made,  examination  of  both  sides  will  determine  whether  the  sen- 
sation imparted  to  the  finger  is  that  from  a  foreign  body,  or 
from  a  normal  fold  of  tensely  stretched  tissue.     If  the  foreign 


FOREIGN    BODIES    IN    THE    (ESOPHAGUS. 


235 


body  is  situated  lower  down  it  may  usually  be  extracted  by  the 
oesophageal  forceps  of  Dr.  Bond,  Fig.  45,  or  by  those  of  Dr. 
Burge,  Fig.  46,  the  instrument  being  oiled  and  wanned,  and 
used  in  the  first  instance  as  a  searcher,  and  subsequently  expanded 
over  the  foreign  body,  care  being  taken  to  attempt  to  seize  it  by 
one  of  its  small  ends  so  as  to  facilitate  its  removal. 


Fig.   45. 


Fig.  46. 


Surge's  Esophageal  Forceps. 


Bond's  Esophageal   Forceps. 

These  forceps  are  bevelled  at  the  edges  so  as  to  prevent  injury 
to  the  mucous  membrane.^  Blunt  hooks  of  various  patterns, 
some  of  which  are  exposed  only  when  past  the  foreign  body, 
are  often  used,  but  are  apt  to  injure  the  mucous  membrane. 

One  of  the  best  of  these  is  a  double  conical  hook,  swivelled 


'  Forceps  formed  of  links  have  been  made.     A  pair  of  this  kind  is  pictured 
in  Oaz.  Mebdomadaire.     1869.     No.  10,  p.  154. 


236 


SPECIAL    AFFECTIONS    OF    THE    (ESOPHAGUS. 


to  the  conducting  rod,  with  the  larger  and  projecting  portions 
upwards.      This  is  intended  to  be  pusheifi  past  the  obstruction, 
and  then  drawn  back,  when  one  of  the  projecting  wings  will 
pjg  47  catch  in  the  foreign  body  and  bring  it  out 

with  it.  As  the  foreign  body  is  usually  of 
larger  size  than  the  swivel,  the  mucous 
membrane  of  the  oesophagus  is  protected 
from  injury  in  the  withdrawal  of  the  in- 
strument. For  large  pieces  of  bone,  and 
other  hard  substances,  this  instrument  is 
often  admirably  adapted.  It  is  sometimes 
called  a  coin-catcher.  Bags  of  silk  and 
gauze,  attached  to  whalebone  rods,  to  be 
pushed  past  the  body  and  then  catch  it  as 
the  instrument  is  withdrawn,  are  often  em- 
ployed. A  great  deal  of  ingenuity  has  been 
displayed  in  the  invention  of  instruments 
for  the  purpose  of  extracting  foreign  bodies 
from  the  cesophagus,  a  mere  description  of 
which  would  occu23y  many  pages. 

One  of  the  very  simplest  and  best,  and 
which  has  often  done  good  service  in  the 
autlior's  hands,  is  the  old  French  horsehair 
snare  and  probang.  Fig.  47,  which  is  pushed 
into  the  stomach,  the  sponge  on  the  end 
being  oiled  before  introduction.  The 
button  at  the  end  of  the  handle  is  then 
pulled  out  of  the  tube,  and  with  it  the 
rod  to  M'hich  the  sponge  is  attached.  This 
makes  a  circular  snare  of  the  horsehair  as 
seen  in  the  lower  drawing,  in  the  meshes 
of  which  the  body  is  caught  and  thus  di-awn 
into  the  mouth. 

When  the  body  is  of  a  nature  such  as 
the  gold-plate   in   the    case   narrated,  the 

Horsehair  snare  and  pro-    prOpCr    Operation  WOuld    bc  tO   bcud    it    Up 

bangforthe  extraction  of  for-  with  a  stroug  pair  of  forccps  aud  tlicn  to 

eign  bodies  from  the  oesopha-  ,  ^  ■'- 

gu8.  extract   it.     -biad   such  a  procedure  been 


rOEEIGlS"    BODIES    IN    THE    (ESOPHAGUS.  237 

instituted  in  that  case,  the  man's  life  wonlcl  not  have  been 
sacrificed.  ■- 

Wlien  the  foreign  substance  is  one  susceptible  of  digestion, 
and  cannot  be  removed  bj  instruments,  it  may  safely  be  pushed 
down  into  the  stomach  by  means  of  a  stout  probang  armed  with 
a  moistened  sponge.  Even  when  not  digestible,  if  of  such  a 
form  that  there  is  no  danger  of  wounding  the  mucous  membrane, 
it  may  be  pushed  down,  for  cases  are  plenty  in  which  coins  and 
other  substances  swallowed  by  children  have  traversed  the  intesti- 
nal tract  and  been  discharged  from  the  rectum.  A  body  must 
be  pushed  down  with  great  care,  especially  if  it  have  any  sharp 
corners,  or  serious  injury  may  be  produced.  Prof.  Stromeyer 
mentions  an  instance  in  which  the  pleura  was  penetrated,  pro- 
ducing death.     Another  case  is  reported  by  Thomas  Green.' 

The  retention  of  a  foreign  body  in  the  oesophagus  is  some- 
times productive  of  death. 

A  case  is  mentioned  by  Mr.  Lee,^  in  which  a  copper  half- 
penny had  been  swallowed  by  a  child  of  five  years  of  age. 
It  was  forced  into  the  stomach.  Enteritis  followed,  result- 
ing in  death.  The  coin  could  not  be  found  on  the  post-mortem 
examination.  The  death  was  due  to  the  mechanical  irritation 
produced  by  the  passage  of  the  coin  through  the  intestinal  tract, 
and  to  poisoning  by  the  copper,  evidences  of  the  existence  of 
which  in  considerable  quantities  was  discovered  on  testing  the 
mucous  membrane  and  contents  of  the  intestines, 

A  case  is  reported  by  Dr.  Alex.  Steven'  in  which  a  nail  pro- 
duced caries  of  the  spine  with  secondary  consolidation  of  lung, 
amyloid  disease  of  liver  and  spleen,  etc.,  producing  death. 

The  presence  of  a  counterfeit  coin  some  twelve  months  in  the 
oesophagus  of  a  convict  produced  ulceration  and  perforation  of 
the  aorta.* 

Many  other  cases  of  similar  nature  are  on  record,  showing  the 
necessity  that  exists  for  making  due  attempts  to  extract  a  foreign 
body  from  the  oesophagus. 

1  Brit.  Med.  Jour.,  Dec.  17,  1870,  p.  650. 

^  St.  G-eorge's  Hospital  Reports,  Vol.  iv.  1869,  p.  219. 

=  Brit.  Med.  Jour.  Dec.  10,  1870,  p.  629. 

*  N.  Y.  Med.  Jour.,  Dec.  10,  1869,  p.  335. 


238  SPECIAL    AFFECTIOlSrS    OF    THE    (ESOPHAGUS. 

-  When  the  foreign  body  is  firmly  lodged  and  the  symptoms  of 
distress  or  danger  to  life  are  severe,  the  operation  of  pharyngoto- 
my  or  of  cesophagotomy  is  called  for,  and  offers  a  fair  promise 
of  success.  Several  very  satisfactory  cases  of  this  kind  are  on 
record. 

Foreign  bodies  sometimes  remain  for  months  and  years  in  the 
pharynx  and  oesophagus,  and  cause  comparatively  little  suffering. 
They  are  sometimes  discharged  spontaneously ;  sometimes,  as  in 
the  case  of  needles  and  pins,  they  work  their  way  to  the  surface, 
and  to  any  part  of  the  surface,  in  fact ;  and  sometimes  they  are 
dislodged,  and  can  be  extracted  by  means  of  the  forceps  or  snare. 
It  is  probable  that  they  become  encysted  in  some  cases,  and  in 
others  produce  an  abscess,  with  the  contents  of  which  they  are 
discharged. 

A  remarkable  case  of  transit  of  foreign  body  came  under 
the  author's  notice  some  years  ago,  in  the  person  of  a  very  old 
man,  who  in  his  youth  had  swallowed  two  pins.  The  old- 
fashioned  pins  with  the  twisted  heads  could  be  distinctly  felt 
under  the  skin  over  one  of  the  man's  shoulders,  where  they  had 
remained  for  more  than  thirty  years,  the  individual  declining  to 
have  them  cut  down  upon  and  removed.  They  went  into  his 
coffin  with  him. 

Prof.  Stromeyer  mentions  a  case  in  which  a  needle  had 
been  swallowed,  the  passage  of  which  he  followed  for  ten  days 
into  the  stomach  and  through  the  left  lung,  where  it  produced 
bloody  expectoration.  These  needles  pass  likewise  into  other  or- 
gans, and  produce  inflammation.  Sometimes  a  bundle  of  needles 
is  swallowed  with  suicidal  intent,  and  produces  death  after  a  long 
series  of  years, 

A  curious  case  is  narrated'  in  which  an  insane  woman  swal- 
lowed a  fork  with  the  expectation  of  dying  under  the  operation 
which  would  have  to  be  performed  for  its  removal.  An  abscess 
formed  in  the  abdominal  walls,  from  which  the  fork  was  remov- 
ed ;  and  after  this  the  patient  recovered. 

In  cases  where  extraction  through  the  mouth  is  impossible, 
and  where  the  operation  of  cesophagotomy  is  contra-indicated, 


{Mediz.  Jahrb.,  1867,  Vol  I.)  Oaz.  Med.  Strasbourg,  1868,  p.  20. 


FOREIGN   BODIES    liST    THE    (ESOPHAGUS.  239 

the  case  must  be  treated  on  general  principles,  or  expectantly. 
Rest  of  body,  nourishment  by  enema,  tonics  by  enema  or  hypo- 
dermically,  would  constitute  the  general  plan  of  management. 
Should  an  abscess  form  and  point  externally,  it  should  be  early 
cut  down  upon. 

Some  individuals  are  subject  to  a  recurrence  of  the  lodge- 
ment of  articles  of  food  in  the  pharynx  or  oesophagus  from  lia- 
bility to  spasm  of  the  constrict  or  muscles  of  the  pharynx  or  of 
the  circular  fibres  of  the  oesophagus.  The  swallowing  of  a 
bolus  on  top  of  the  arrested  morsel,  or  of  a  copious  draught  of 
water,  usually  suffices  to  force  the  body  down.  If  this  does  not 
answer,  the  services  of  a  surgeon  are  required  to  accomplish  the 
purpose  with  the  probang. 

A  recurrence  of  the  accident  may  be  sometimes  avoided  by 
the  repeated  passage  of  the  oesophageal  bougie,  wliich  obtunds 
the  sensibilities  of  the  parts  and  thus  renders  them  less  liable  to 
spasm.  In  some  instances  of  this  kind,  the  frequent  recurrence 
of  the  paroxysm  points  to  the  formation  of  an  organic  stricture, 
and  if  there  be  reason  to  believe  that  such  is  the  case,  the  pas- 
sage of  the  sound  is  the  more  strongly  indicated. 

FANCIED    BODIES    IN    THE    PHAKYNX    AND    (ESOPHAGUS. 

Hysterical  patients  often  fancy  that  they  havQ  a  foreign 
body  in  the  throat.  We  sometimes  meet  cases,  not  at  all  asso- 
ciated with  hysteria,  in  which  this  fancy  -exists.  The  parts 
are  normal  on  inspectiou,  but  the  patient  cannot  be  dissuaded 
from  the  idea  of  the  presence  of  a  foreign  body.  Sometimes 
this  condition  is  attended  with  an  unwillingness,  or,  perhaps, 
an  inability  to  swallow  solid  nutriment,  but  not  from  any 
paralysis  of  the  constrictor  muscles  of  the  pharynx,  as  these 
contract  readily  on  being  titillated.  Sometimes,  too,  there 
is  a  vague  dread  of  suffocation.  Occasionally  there  is  a  true 
history  of  a  foreign  body  which  has  probably  been  expelled. 
The  position  occupied  by  the  fancied  body  often  clianges.  At  one 
interview  it  will  be  in  the  oesophagus ;  at  another,  at  the  upper 
part  of  the  pharynx,  and  so  on.  Sometimes  the  sensitive  point 
will  be  changed  by  the  swallowing  of  a  glass  of  water,  or  a 
solid  morsel,  or  the  passage  of  the  oesophageal  sound. 


240  SPECIAL    AFFECTIONS    OF    THE    CESOPHAGUS. 

Occasionally  a  small  point  of  ulceration  in  the  pharynx  will 
be  found  as  the  source  of  trouble,  especially  in  those  cases 
where  the  sensation  of  a  foreign  body  is  increased  by  swallow- 
ing. In  other  cases  the  affection  is  dependent  upon  some 
disturbance  of  the  nervous,  digestive,  or  uterine  system.  Other 
cases  must  be  regarded  as  pure  neuralgias ;  and  there  is  no 
doubt  that  some  j)atients  suffer  a  good  deal.  The  affection  is 
often  associated  with  anaemia  and  debility. 

These  cases  are  sometimes  of  long  standing,  and  very  obdu- 
rate to  treatment. 

The  internal  administration  of  iron,  quinine,  strychnia,  or 
arsenic,  alone  or  in  combination,  with  attention  to  any  specially 
deranged  functions,  will  form  the  most  appropriate  general  treat- 
ment, while  the  local  sensibilities  of  the  parts  may  often  be 
materially  modified,  and  sometimes  promptly  subdued  by  the 
application  of  solutions  of  nitrate  of  silver,  or  some  substitute 
for  it;  and  a  similar  effect  will  sometimes  follow  the  use 
of  the  electric  current,  with  the  positive  pole  in  contact  with 
the  parts. 

Cases  dependent  upon  actual  ulceration  are  usually  promptly 
relieved  by  a  few  applications  to  the  ulcer  of  nitrate  of  silver 
or  a  mineral  acid — sometimes  by  a  single  application. 

(ESOPHAGOTOMY. 

CEsophagotomy  is  the  term  under  which  are  included  all 
operations  for  gaining  access  to  the  oesophagus  or  the  pharynx 
from  the  exterior  of  the  body.  When  the  opening  is  made 
into  the  pharynx,  the  operation  performed  has  been  pharyngo- 
tomy;  but  it  is  nsual.to  consider  the  two  operations  under  the 
same  head,  inasmuch  as  their  line  of  demarcation  is  not  very 
distinct,  anatomically  or  surgically. 

Operations  of  tliis  kind  have  not  been  performed  \evy  fi*e- 
quently,  twenty-five  or  thirty  of  them  representing,  perhaps, 
the  entire  number  on  record. 

The  indications  for  an  operation  of  this  kind  are  presented 
in  cases  of  a  foreign  body  in  the  tube  which  cannot  be  re- 
moved by  other  means ;  in  cases  of  constriction  of  the  tube 
fi'om   organic   stricture,   or  the   pressure  of   a   tumor  on  the 


(ESOPHAGOTOMY.  ,  241 

outside,  in  order  to  afford  a  means  of  conveying  nourishment 
into  the  stomach.  It  has  also  been  performed  in  dysphagia, 
fi-om  laryngeal  ulceration,  and  in  a  case  of  this  kind  performed 
by  Dr.  John  Watson,  of  New  York,  the  patient  was  nourished 
for  three  months,  when  he  died  of  pneumonia.  The  operation 
has  been  suggested  also  for  removal  of  a  diverticulum  or 
pouch  of  the  pharynx  or  oesophagus,  and  also  for  gaining 
access  to  abscesses  in  the  tube  threatening  to  rupture  into  the 
trachea. 

The  following  method  for  performing  this  operation — for 
foreign  body  in  the  oesophagus— is  recommended  in  Gross's 
Surgery : — 

"The  neck  being  stretched,  the  head  retracted,  and  the 
foreign  substance  made  to  project  as  far  as  possible  on  the 
left  side  of  the  windpipe,  an  incision,  several  inches  in  length, 
is  made  directly  over  the  swelling,  through  the  skin  and 
platysma-myoid  muscle.  The  tube  being  thus  exposed,  and 
any  vessels  and  nerves  that  may  be  in  the  way  held  aside, 
its  wall  is  divided  to  the  requisite  extent,  and  the  substance, 
whatever  it  may  be,  is  extracted  with  the  finger  or  forceps, 
as  may  be  found  most  convenient.  As  soon  as  clearance  has 
been  effected,  and  the  bleeding  arrested,  the  edges  of  the 
oesophageal  wound  are  neatly  approximated  by  several  points 
of  the  interrupted  suture,  made  with  very  fine  but  strong 
silk,  the  ends  being  cut  off  close  to  the  knot,  to  afford  the 
ligatures  an  opportunity  of  dropping  ultimately  into  the  interior 
of  the  passage.  The  cutaneous  wound  being  dressed  in  the 
usual  manner,  the  case  is  managed  upon  general  principles, 
the  patient  being  supported  during  the  first  week  with  broths, 
conveyed,  if  necessary,  by  means  of  a  tube,  or,  what  will  be 
better,  introduced  into  the  rectum." 

A  very  excellent  history  of  the  operation,  with  a  tabular 
statement  of  all  the  cases  that  the  author  could  find  on  record 
at  the  time,  and  including  two  of  his  own,  was  recently  pub- 
lished '  by  Dr.  David  W.  Cheever,  of  Boston.  To  this  we  refer 
our  readers  for  detailed  information  on  this  special  subject. 

'  Two  Cases  of  CEsophagotomy  for  the  Removal  of  Foreign  Bodies ;  with  a. 
History  of  the  Operation.     Boston,  1867. 

16 


242  SPECIAL    AFFECTIOlSrS    OF    THE    (ESOPHAGUS. 

A  perusal  of  the  cases  collected  by  various  authors  shows 
that  the  operation  is  not  without  danger,  only  nine  out  of 
the  sixteen  operations  for  removal  of  a  foreign  body  collected  by 
Giinther'  having  been  reported  as  successful;  a  result  quite 
different  from  that  recorded  in  Dr.  Cheever's  pamphlet,  which 
includes  most  of  the  cases  collected  by  Giinther,  but  which  gives 
the  successful  cases  as  numbering  thirteen  out  of  seventeen. 
In  three  of  the  cases  in  Prof.  Giinther's  list,  in  which  he  could 
not  ascertain  the  result,  success  may  have  followed,  as  two  of 
them  (Begin,  1832)  are  so  recorded  by  Dr.  Cheever. 

The  operation  of  oesophagotomy  should  not  be  unnecessarily 
delayed  when  once  determined  upon,  on  account  of  the  risk  of 
permanent  or  irreparable  injury  from  inflammation,  suppura- 
tion, etc. ;  and  on  account  of  the  propriety  of  affording  nourish- 
ment by  the  natural  passage  as  soon  as  possible. 

When  the  foreign  body  cannot  be  felt  from  the  outside,  a 
metallic  sound  should  be  passed  into  the  CEs6j)hagus,  and 
pressed  against  the  external  tissues  so  as  to  act  as  a  guide  for 
the  place  of  incision,  and  to  insure  penetration  into  the  interior 
of  the  tube.  Even  when  the  foreign  body  lies  below  the  region 
of  the  neck  affording  access  to  the  oesophagus,  the  operation  is 
justifiable  as  presenting  a  better  facility  for  the  manipulation  of 
the  forceps.  If  the  wound  has  to  be  dilated  for  this  pui-pose, 
care  must  be  taken  not  to  injure  important  vessels  or  nerves. 
In  one  of  the  cases  operated  on  by  Dr.  Cock"  there  was  a  per- 
manent alteration  of  the  voice,  probably  due  to  some  injury 
inflicted  uj)on  the  recurrent  laryngeal  nerve. 

'  Lehre  von  den  blutigen  Operationen.     Leipzig,  1864.    Vol.  V.  p.  269. 
*  Oufs  Hospl  Bep.  1858,  p.  217. 


AFFECTION'S    OF    THE    N"ASAL    PASSAGES.  243 


CHAPTER    XII. 

AFFECTIONS    OF  THE    ISTASAL    PASSAGES. 

The  Nasal  Mucous  Membrane — The  nasal  mucous  mem- 
brane is  very  often  the  seat  of  disease,  and  participates  very 
readily  in  the  affections  of  the  neighboring  structures.  A  brief 
survey  of  some  of  the  points  of  its  anatomical  structure  will  aid 
in  the  study  of  the  diseases  to  which  it  is  subject. 

The  lining  membrane  of  the  nostrils  is  closely  adherent  to 
the  periosteum  of  tlie  bones  constituting  the  framework  of  the 
interior  of  the  nose,  by  connective  tissue  in  which  there  are  no 
fat-cells.  Its  free  surface,  in  the  normal  condition,  is  smooth  as 
a  rule,  except  upon  the  lower  turbinated  bone,  where  it  is  often 
noticed  raised  in  irregular  mulberry-like  projections  the  size  of 
a  hemp-seed,  and  covering  as  much  of  the  bone  as  can  be  seen 
in  the  rhinoscopic  image, — that  is,  its  bulging  portion.  This  gives 
the  part  a  rough  mamelonated  appearance,  which  may  readily 
be  mistaken  for  a  result  of  disease  in  chronic  affections  of  this 
region.  This  extra  thickness  is  in  part  due,  according  to  the 
researches  of  Prof.  KoUiker,  to  rich  plexuses  of  veins  em- 
bedded in  the  tissue.  That  portion  of  the  membrane  covering 
the  septum  of  the  nose  is  also  smooth  as  a  rule,  but  is  some- 
times arranged  in  closely  adherent  rug£e,  giving  it  somewhat 
the  appearance  of  muscular  tissue.  The  membrane  is  richly 
supplied  with  acinous  glands,  which  in  certain  locations,  by 
their  enlargement,  often  become  the  origin  of  nasal  polyps. 
The  epithelium  of  the  mucous  membrane  is  of  the  ciliary 
variety,  and,  in  the  upj^er  portion  of  the  nasal  passages,  has  a 
special  arrangement  which  is  supposed  to  have  some  relation 
with  the  function  of  olfaction. 

The  mucous  membrane  of  the  sinuses  communicating  with 
the  nasal  passages  is  much  less  rich  in  glandular  tissue,  the 
maxillary   sinus   being   better   supplied   in   this   respect   than 


244  AFFECTIONS    OF   THE    IfASAL    PASSAGES. 

either  the  frontal,  sphenoidal,  or  ethmoidal  sinuses.  The 
mouths  of  these  glands  sometimes  become  occluded,  and  give 
rise  to  the  development  of  cysts,  this  result  occurring  most  fi-e- 
quently  in  the  upper  maxillary  bone. 

The  blood-vessels  of  the  nasal  mucous  membrane  are  very 
numerous,  but  not  of  large  size,  and  they  anastomose  very 
fi'eely.  The  arterial  vessels  take  origin  principally  from  two 
sources,  the  internal  maxillary  and  the  ophthalmic  arteries. 
The  spheno-palatine  portion  of  the  internal  maxillary  gives 
off  the  posterior  nasal  artery,  which  passes  into  the  cavity  of  the 
nose  through  the  spheno-palatine  foramen,  and  then  divides  on 
either  side  into  an  outer  and  an  inner  portion.  The  outer  or 
lateral  portion  descends  behind  the  turbinated  bones,  which 
it  supplies,  and,  in  addition  to  supplying  the  nasal  passages, 
supplies  also  the  antrum  and  the  ethmoidal  and  sphenoidal 
cells.  The  inner  or  middle  portion  passes  to  the  septum  and 
divides  into  several  branches,  which  descend  obliquely  for- 
ward, inter-communicating  with  the  artery  of  the  septum,  a 
branch  of  the  external  maxillary  artery.  From  the  oph- 
thalmic is  given  off  the  anterior  ethmoidal  artery,  which 
passes  through  the  anterior  ethmoidal  foramen,  whence  a 
nasal  branch  descends  through  an  opening  in  the  cribriform 
plate  of  the  ethmoid  bone.  It  supplies  the  anterior  portion  of 
the  septum  and  the  lateral  walls  of  the  cavity,  as  well  as  the 
anterior  ethmoidal  cells  and  frontal  sinuses,  before  the  entrance 
of  its  meningeal  branch  into  the  cranium.  The  capillaries  from 
these  various  branches  form  a  close  reticulum  which  penetrates 
the  substance  of  the  mucous  membrane  and  surrounds  the 
glands,  the  anastomosing  capillaries  being  enlarged  aneurismally 
in  some  places. 

The  veins,  in  general,  follow  the  course  of  the  arteries,  with- 
out any  peculiarity  except  on  the  inferior  turbinated  bone, 
where,  as  shown  by  Kohlrausch,  Kolliker,  and  others,  they  form 
a  regular  cavernous  reticulum,  which  is  spread  out  between  the 
periosteum  and  the  mucous  membrane,  increasing  the  thickness 
of  the  parts  to  the  extent  of  some  four  millimetres. 

This  distensible  tissue  favors  the  sudden  stoppage  of  the 
nose   occurring   in   catarrhal   affections   of   the   nasal   mucous 


EPISTAXIS.  245 

membrane,  and  permits  as  prompt  a  snbsidence  mider  the  use 
of  remedies  which  constringe  the  blood-vessels ;  and  it  also  ex- 
plains the  profuseness  of  the  serous  discharge  which  attends 
an  ordinary  catarrh. 

After  adult  life,  the  mucous  membrane  lining  the  nasal 
passages  and  the  sinuses  communicating  with  them  is  liable  to 
become  more  or  less  strewn  with  calcareous  deposits,  which  some- 
times accumulate  in  roundish  or  oval  masses,  and  are  then 
recognized  by  the  eye  as  yellow  spots. 

Aifections  of  the  nasal  mucous  membrane  are  readily  pro- 
pagated to  the  contiguous  sinuses,  and  also  to  the  pharynx  and 
larynx,  as  well  as  to  the  middle  ear,  by  continuity  of  passage 
along  the  Eustachian  tube,  the  pharyngeal  orifice  of  which  is  in 
close  proximity  with  the  outer  posterior  margin  of  the  nasal 
passage  on  either  side,  looking  towards  it  in  a  direction  down- 
wards and  inwards,  as  may  be  seen  by  a  glance  at  the  rhinoscopic 
images. 

In  addition  to  the  ordinary  results  of  inflammation,  abscess,  and 
ulceration,  disease  of  the  nasal  mucous  membrane  is  liable  to 
take  on  a  peculiar  action  productive  of  an  offensive  discharge^ 
due,  no  doubt,  in  some  measure,  to  decomposition  of  the  pent- 
up  products  of  secretion,  but  also  due  in  part  to  some  peculi- 
arity of  tissue,  or  of  action  in  the  tissue,  the  nature  of  which 
still  awaits  demonstration. 

The  bones  of  the  nose,  especially  the  turbinated  bones,  are 
often  involved  in  the  progress  of  inflammation  of  the  nasal  mu- 
cous membrane,  the  inflammatory  action  thus  excited  not  infre- 
C[uently  terminating  in  caries  and  necrosis. 

Extension  of  inflammatory  action  into  the  maxillary  sinus 
sometimes  produces  abscess  and  dropsy  of  the  antrum,  or  re- 
sults in  caries  of  the  upper  maxillary  bone. 

The  various  forms  of  polyp  are  often  met  with  in  this  region, 
as  also  tumors  of  flbrous  and  osseous  composition,  and  those  of 
malignant  nature. 

EPISTAXIS. 

Epistaxis,  bleeding  fi^om  the  nose,  is  of  very  frequent  occur- 
rence. It  may  be  idiopathic  or  traumatic.    Sometimes  it  occurs  as 


246  AFFECTIOlSrS    OF    THE    NASAL    PASSAGES. 

a  vicarious  menstruation.  When  occurring  frequently,  without 
apparent  cause,  and  especially  if  the  blood  be  thin,  copious  in 
quantity,  and  difficult  to  restrain,  it  is  an  evidence  of  the  hem- 
orrhagic diathesis,  and  under  these  circumstances  may  lead  di- 
rectly or  indirectly  to  a  fatal  result.  This  form  appears  most 
fi'equently  in  hojs,  anterior  to  or  just  about  the  period  of 
puberty.  Epistaxis  sometimes  seems  to  occur  as  a  relief  to 
vascular  turgescence  within  the  cranium,  and  this  often  affords 
a  spontaneous  relief  to  a  determination  of  blood  to  the  head, 
and  to  violent  cephalalgia,  noises  in  the  ears,  vertigo,  sleepless- 
ness, dryness,  heat,  or  irritation  of  the  nasal  passages,  etc. 
This  form  of  epistaxis  is  usually  from  one  nostril  only,  but 
occasionally  proceeds  from  both.  Sometimes  the  blood  pours 
out  in  a  continuous  stream,  but  more  frequently  drop  by  drop. 

Bleeding  from  the  nose  sometimes  attends  certain  diseases  at 
their  commencement,  such  as  remittent  and  enteric  fevers ;  and 
indeed,  in  combination  with  other  symptoms,  is  regarded  in  some 
measure  as  pathognomonic  of  enteric  fever ;  though  it  is  well 
known  to  attend  other  affections,  such  as  scurvy,  purpura,  dis- 
ease of  the  spleen,  etc.  Sometimes  it  occurs  at  the  so-called 
critical  periods  of  pneumonia  and  various  fevers. 

It  may  occur  in  several  local  diseases  as  a  result  of  ulceration ; 
in  chronic  rhinorrhcea,  especially  that  form  known  as  ozoena ;  and 
it  may  attend  disease  of  the  cartilage  or  bone,  or  be  connected 
with  the  disturbance  occasioned  by  the  presence  of  a  foreign 
body,  a  polyp,  or  other  growth,  or  a  calcareous  concretion  either 
in  the  nasal  passage  itself,  or  in  one  of  the  communicating 
sinuses. 

Epistaxis  may  be  occasioned  by  violent  sneezing,  whether 
occurring  spontaneously,  or  as  a  result  of  snuffing  ujd  irritating 
substances;  and  it  also  follows  external  injuries,  sucli  as  falls 
upon  the  part,  or  a  direct  blow  from  the  list,  whether  there  be 
fracture  produced  or  not.  Sometimes  it  is  produced  by  picking 
the  nostril.  It  is  not  unfrequently  encountered  in  the  aged  as  a 
perfectly  physiological  process,  or  in  relief  of  various  congestions 
of  the  head  or  face. 

Spontaneous  epistaxis  sometimes  follows  exposure  to  cold,  or 
exposure  to  immoderate  heat  after  exposure  to  cold. 


EPISTAXIS.  247 

A  passive  form  of  epistaxis  sometimes  occurs  in  connection 
with  organic  disease  of  the  heart,  with  extensive  exndation  into 
the  pleural  sac,  in  emphysema  of  the  lungs,  in  cases  of  goitre, 
etc.,  from  the  impediment  offered  to  the  free  return  of  the 
circulating  blood  to  the  heart.  It  is  also  occasionally  met  with 
in  various  affections  of  the  abdominal  viscera,  su.ch  as  ascites, 
ovarian  dropsy,  etc.,  on  account  of  the  pressm'e  exerted  upon  the 
diaphragm,  impeding  free  respiration,  and  thus  inducing  a  stasis 
of  the  venous  circulation. 

Hemorrhage  from  the  nose,  as  also  from  other  outlets,  has 
been  known  to  occur  from  diminution  of  atmospheric  pressure 
in  ascending  lofty  mountains,  and  cases  of  this  kind  have  been 
narrated  by  Humboldt  as  occurring  at  Chimborazo,  by  Saussure 
at  Mont  Blanc,  by  Bouguer  at  the  peaks  of  the  Cordilleras,  etc. 

Epistaxis  has  been  known  to  occur  sometimes  in  infantry 
soldiers  fatigued  by  long  marches  in  hot  weather. 

Care  must  be  taken  in  certain  instances  to  distinguish  epi- 
staxis escaping  posteriorly  from  hemoptysis ;  and  also  from 
hsematemesis,  which  it  may  simulate  by  having  been  swallowed 
in  sleep,  and  then  subsequently  ejected  by  vomiting.  In  like 
manner  the  blood  of  epistaxis,  if  swallowed  and  not  vomited, 
may  simulate  hemorrhage  from  the  bowel. 

The  bleeding  from  the  nose  is  usually  confined  to  one  of  the 
nostrils,  a  hemorrhao;e  from  both  beino'  uncommon.  As  a  usual 
thing  it  is  not  very  profuse,  and  soon  ceases  spontaneously ;  but 
it  sometimes  lasts  for  hours,  in  exceptional  cases  for  days,  and  it 
may  at  once  from  its  copiousness,  or  gradually  from  its  contin- 
uance, induce  fainting,  or  even  terminate  fatally.  Cases  have 
been  narrated  in  which  epistaxis  appeared  periodically,  return- 
ing at  the  same  hour  every  day,  like  the  paroxysm  of  an  inter- 
mittent, and,  like  it,  amenable  to  the  influence  of  quinine. 
Spontaneous  cessation  is  due  to  the  formation  of  a  coagulum, 
just  as  when  excessive  bleeding  is  stopped  by  the  tampon ;  and  if 
the  coagulum  is  dislodged  too  early  by  sneezing,  coughing,  or 
.using  the  handkerchief ,  the  epistaxis  is  very  likely  to  reoccur. 

Treatment  of  Ejnstaxis. — When  epistaxis  occurs  as  a  physio- 
logical or  salutary  process,  it  usually  subsides  sj^ontaneously. 
When  so  profuse  as  to  threaten  serious  injury,  it  is  necessary  to 


248  AFFECTTOlSrS    OF   THE    ]S)ASAL    PASSAGES. 

resort  to  mechanical  measures  to  restrain  the  hemorrhage.  In 
cases  where  it  occurs  frequently,  or  recurs  several  times  a  day 
for  weeks  at  a  time,  we  resort,  in  addition,  to  the  internal  ad- 
ministration of  astringents,  and  other  remedies  which  tend  to 
contract  the  blood-vessels. 

The  local  action  of  cold  applied  to  the  parts  affected,  or  to 
the  neighboring  parts,  constringes  the  vessels  and  favors  the 
formation  of  a  clot.  For  this  purpose  we  use  cold  water,  or  ice 
compresses,  upon  the  nose,  the  forehead,  or  the  neck.  The  well- 
known  remedy  of  placing  a  street-door  key  upon  the  skin  of  the 
back  acts  somewhat  on  this  principle,  although  some  of  the  in- 
fluence of  this  and  similar  remedies  is  doubtless  attributable  to 
the  reflex  action  of  the  cold  upon  the  vaso-motor  system  of  nerves. 

We  can  sometimes  stop  the  bleeding  mechanically  by  simple 
pressure  upon  the  nostril,  maintained  during  several  minutes  ; 
the  bleeding  is  very  often  from  the  artery  of  the  septum,  which 
can  be  readily  compressed  in  this  manner.  The  amount  of  blood 
passing  to  the  bleeding  vessels  can  sometimes  be  reduced  by 
raising  both  arms  above  the  head,  and  thus  favoring  the  formation 
of  a  clot,  forcing  the  blood  reaching  these  parts  to  mount  against 
gravity,  and  thus  lessen  the  force  upon  the  bleeding  vessels. 
An  excellent  plan,  acting  upon  a  combination  of  these  two  pro- 
cesses, was  introduced  by  Dr.  Negrier,'  which  consists  in  com- 
pressing the  bleeding  nostril  by  the  finger  of  the  opposite  hand, 
and  raising  the  arm  of  the  affected  side  high  above  the  head. 

Dr.  Chapman  employs  his  water-bag  between  the  shoulders, 
the  water  being  at  a  temperature  of  105°,  This  acts  uj)on  the 
principle  of  calling  a  larger  portion  of  the  blood  to  a  distant  sur- 
face. For  the  same  purpose  mustard  has  been  applied  over  the 
stomach,  or  upon  the  ankles.  Junod  resorts  to  his  famous  boot, 
which  produces  an  extensive  dry  cupping  of  the  leg.  Others 
confine  the  blood  in  one  of  the  extremities  by  compressing  the 
limb  above  the  knee,  or  above  the  elbow,  with  a  ligature. 

When  simple  mechanical  measures  or  the  local  application  of 
cold  fails  to  restrain  the  hemorrhage,  we  must  resort  to  the 
local  application  of  mineral  or  vegetable  astringents.  These 
may  be  injected  into  the  parts,  in  solution  or  in  powder ;  or  they 

'  Arch  Oen.  de  Med.,  June,  1843,  p.  168. 


EPiSTAxrs.  249 

may  be^applied  by  means  of  pledgets  of  lint  or  sponge  soaked 
in  the  solution,  or  sprinkled  over  with  the  powder.  The  materials 
employed  are  the  ordinary  astringents  and  haemostatics,  such  as 
solutions  of  alum,  sulphate  of  zinc,  acetate  of  lead,  sulphate  of 
iron,  etc.,  or  solutions  of  tannic  or  gallic  acid,  decoctions  of 
Krameria,  etc. 

When  internal  remedies  are  necessar}^  to  prevent  the  recur- 
rence of  bleeding  we  select  the  direct  haemostatics,  and  other 
articles  of  the  materia  medica  which  produce  contraction  of  the 
small  arteries.  Thus  we  administer  tincture  of  the  chloride  of 
iron,  ergot  in  tincture  or  in  fluid  extract,  turpentine,  bromide 
of  potassium,  belladonna,  and  so  on.  These  remedies  are  given 
at  frequent  intervals,  and  in  small  doses. 

When  the  epistaxis  is  distinctly  periodic  in  character,  we 
employ  quinine. 

During  this  time,  rest  of  body  and  of  mind  must  be  enjoined, 
with  the  maintenance  of  the  recumbent  or  sitting  posture, 
avoiding  such  movements  as  bring  the  head  forwards,  removing 
all  constrictions  of  the  clothing  about  the  neck,  chest,  and 
abdomen ;  and  refraining  as  much  as  possible  from  loud  talking, 
cou^ghing,  sneezing,  snuffling,  and  the  use  of  the  pocket-handker- 
chief. The  food  taken  should  not  be  stimulating,  nor  too  warm; 
and  when  all  disposition  to  epistaxis  has  ceased  for  the  time,  a 
somewhat  similar,  though  less  rigid  regimen,  should  be  kej)t  up 
for  some  time,  care  being  taken  to  promote  the  due  action  of 
the  skin,  kidneys,  and  bowels. 

Where  there  exists  local  disease  or  injury  as  the  cause  of  the 
epistaxis,  these  conditions  demand  prompt  attention. 

When  the  epistaxis  cannot  be  restrained  by  ordinary  means, 
or  where  it  is  very  copious,  resort  must  be  had  to  the  tampon 
for  the  purpose  of  plugging  up  the  passages,  and  thus  favoring 
the  formation  of  a  clot.  Plugging  the  nostrils  anteriorly  is  easilv 
enough  done,  but  occluding  the  nares  posteriorly  is  a  much  more 
difficult  procedure.  When  no  special  instrument  for  this  pur- 
pose is  at  hand,  a  doubled  wire,  an  eyed  catheter  or  probe,  or  a 
substitute  made  of  whalebone,  is  passed  along  the  floor  of  the 
nose  into  the  pharynx,  whence  it  is  drawn  into  the  mouth  by  the 
finger.     A  stout  thread,  which  has  been  secured  to  a  small  roll 


250  AFrECTIO]S"S    OF   THE    ISTASAL    PASSAGES. 

of  lint  or  a  piece  of  sponge,  is  now  attached  to  the  eye  of  the 
catheter  or  the  loop  of  the  wire,  and  as  the  latter  is  withdrawn 
from  the  nostril  it  carries  the  thread  of  the  tampon  with  it,  and, 
as  the  thread  is  drawn  upon,  the  passage  of  the  tampon  behind 
the  palate  and  against  the  orifice  of  the  nares  is  assisted  by  the 
forefinger  of  the  operator. 

The  best  instrument  for  accomplishing  this  purpose  is  the 
canula  of  Bellocq  (Fig.  48).      It  consists  of  a  metallic  tube, 

Fig.  48. 


Canula  of  Bellocq  for  Plugging  Posterior  Nares. 

which  is  to  be  passed  through  the  nostril  into  the  pharynx ;  a 
rod  on  the  exterior,  when  pressed  upon,  forces  a  steel  spring  into 
the  mouth ;  to  this  steel  spring  a  perforated  knob  is  soldered, 
affording  a  means  of  attachment  for  the  thread  which  is  to  carry 
the  tampon  against  the  posterior  nares. 

The  plugs  should  be  removed  after  the  lapse  of  forty-eight 
hours,  and  the  nostrils  well  cleansed  by  means  of  the  syringe  ; 
and  if  there  is  any  return  of  hemorrhage,  fresh  tampons  can  be 
applied.  Prof.  Gross  mentions,  in  his  System  of  Surgery,  that 
he  has  seen  several  cases  terminate  fatally,  with  low  fever  and 
delirium,  from  systemic  poisoning  produced  by  too  long  a 
retention  of  the  plugs. 

NASAL   ABSCESS. 

Abscess  of  the  interior  of  the  nose  is  not  a  common  affection, 
yet  is  one  occasionally  met  with,  sometimes  as  a  result  of 
traumatic  injury,  and  sometimes  in  the  course  of  a  common 
chronic  coryza.  Once  in  a  while  abscesses  are  seen  without  any 
apparent  cause  of  origin,  except  perhaps  exposure  to  a  sudden 
change  of  temperature  from  heat  to  cold,  or  from  cold  to  heat, 
and  sometimes  without  even  that  cause. 

These  abscesses  are  formed  in  the  submucous  connective  tissue. 


COEYZA.  251 

They  usually  affect  the  lower  portion  of  the  nasal  cavity,  princi- 
pally the  septum,  and  not  far  from  the  external  orifice.  Some- 
times they  are  very  small  and  circumscribed,  looking  like  little 
boils.  Sometimes  they  are  very  large,  large  enough  to  occlude 
the  nostril  of  the  affected  side,  and  to  press  the  septum  over 
towards  the  opposite  side. 

The  abscess  is  usually  acute,  the  inflammation  sometimes 
affecting  the  submucous  cellular  tissue  primarily,  and  some- 
times secondarily  as  a  result  of  inflammation  of  the  cartilage 
of  the  septum.  There  is  redness  with  turgescence  of  the 
adjacent  mucous  membrane,  swelliug,  increased  secretion,  and 
intense  pain.  Sometimes  the  entire  nose  is  swollen,  red,  and 
painful,  this  condition  occasionally  extending  over  more  or  less 
of  the  skin  of  the  face,  which  may  even  become  oedematous. 

Febrile  symptoms  are  present  in  severe  cases,  and  are  pro- 
portionate to  the  violence  of  the  local  action. 

The  affection,  left  to  itself,  subsides  in  a  few  days  by  a  spon- 
taneous rupture  of  the  abscess ;  but  it  is  a  better  pi-actice 
to  open  it  artificially  at  an  early  date.  The  after-treatment 
would  consist  in  the  local  application  of  warm  water  injections, 
impregnated,  if  need  be,  with  narcotic  or  astringent  ingredi- 
ents. If  the  surrounding  inflammation  is  severe,  a  leech, 
confined  in  a  tube  which  will  not  let  his  body  escape  through 
the  orifice,  may  be  applied  within  the  nostril  with  relief. 

COEYZA. 

Coryza  is  an  acute  catarrhal  inflammation  of  the  mucous 
membrane  lining  the  nasal  cavities.  It  is  popularly  known  as 
a  cold  in  the  head,  and  has  been  called  rhinitis,  rhinorrhoea, 
gravedo,  etc.,  by  some  authors. 

The  inflammation  is  often  confined  to  a  single  nostril,  but 
usually  affects  both,  and  often  extends  to  the  mucous  lining  of 
the  maxillary  sinus,  the  frontal  sinus,  the  lachrymal  duct,  or 
the  Eustachian  tube,  sometimes  involving  several  of  these 
structures,  or  all  of  them,  at  the  same  time.  There  are  redness 
and  swelling  of  the  mucous  membrane,  attended  at  first 
with  dryness,  but  subsequently  with  a  more  or  less  copious 
secretion,  which   varies   in   quality   at   different  stages  of  the 


252  AFFECTIONS    OF   THE   JSTASAL   PASSAGES. 

affection.  In  exceptional  cases  the  inflammation  is  attended 
with  the  exudation  of  a  fibrinous  secretion,  which  concretes  in 
the  fonn  of  a  membranous  layer,  similar  in  some  respects 
to  that  of  diphtheria,  but  altogether  different  in  character. 
This  membranous  variety  is  encountered  more  frequently  in  the 
coryza  of  the  new-born  infant,  and  in  the  coryza  attending  the 
exanthemata. 

The  general  sj^mptoms  vary,  from  the  merest  consciousness 
of  disturbance  to  the  condition  of  severe  pain,  fever,  loss 
of  appetite,  headache,  insomnia,  mental  and  physical  debility, 
etc.  The  earliest  symptoms  are  a  sense  of  dryness  and  irritation 
in  the  nose,  exciting  the  disposition  to  sneeze,  which  relieves 
the  uneasy  sensation  for  the  moment.  After  more  or  less  con- 
tinuance of  these  symptoms,  a  sense  of  fulness  in  the  parts  will 
be  experienced,  with  some  difficulty  in  nasal  respiration,  often 
amounting  to  complete  obstruction,  so  that  the  mouth  must  be 
kept  partially  open  to  insure  freedom  of  breathing.  With  this 
there  soon  occurs  an  obtuseness  in  the  sense  of  smell,  and  so 
much  of  that  of  taste  as  is  dependent  on  the  sense  of  smell.  The 
voice  will  assume  the  peculiar  nasal  tone  it  acquires  when  one 
voluntarily  closes  the  nostrils  in  speaking.  There  will  be  more 
or  less  pain  in  the  parts,  extending  to  the  frontal  and  malar 
regions  in  proportion  as  the  sinuses  in  these  situations  become 
involved  in  the  inflammation.  The  pain  in  these  regions 
is  often  extremely  severe  and  hard  to  bear.  If  the  lachrymal 
duct  is  involved  there  will  be  pain  in  that  locality,  with  pain 
of  the  injected  conjunctiva  on  pressure  or  exposure  to  light, 
attended  sometimes  with  other  local  optic  phenomena.  If  the 
inflammation  has  extended  to  the  Eustachian  tube,  there  will  be 
pain  in  the  region  of  the  ears,  with  abnormal  auditory  sounds, 
and  more  or  less  dulness  of  hearing.  If  the  inflammation 
tra^•els  down  the  pharynx,  we  shall  have  sore  throat ;  and  if  it 
attacks  the  upper  air-passages,  as  not  unfrequently  haj^pens, 
we  shall  have  added  the  symptoms  of  catarrhal  laryngitis,  or  of 
bronchitis,  or  both. 

The  amount  of  fever  will  be  greater,  the  greater  the  extent 
of  tissue  involved.  Sometimes  this  tissue  is  not  confined 
to  the  respiratory  tract  by  any  means,  but  the  whole  body  will 


COETZA.  253 

feel  sore  and  out  of  sorts,  the  joints  and  limbs  responding  as 
to  an  attack  of  sub-acute  rheumatism. 

The  sense  of  fulness  or  stuffing  of  the  parts  is  very  uncom- 
fortable, and  futile  efforts  to  expel  matters  from  the  nostrils  are 
made  during  the  early  stage  of  the  affection,  when  the  mucous 
membrane  is  dry;  and  these  efforts  become  more  frequent,  and 
of  course  more  effective,  after  the  establishment  of  the  stage  of 
secretion.  The  cause  of  the  dryness  of  the  mucous  membrane 
in  the  earlier  stage  of  coryza  is  not  well  understood.  In  the 
healthy  state  the  mucous  membrane  of  the  nose  does  not 
secrete  mucus,  or  even  serum.  Many  individuals  have  no 
occasion  at  all  to  use  the  handkerchief  for  the  removal  of  any 
nasal  secretion,  unless  it  be  excited  by  the  inspiration  of  dust, 
irritating  vapors,  etc.  The  membrane  is  constantly  moist,  it 
is  true,  but  it  is  not  so  by  reason  of  any  secretion,  but  in  conse- 
quence of  an  absorption  of  the  moisture  condensed  upon  it  from 
the  breath  of  expiration.  When  the  membrane  is  chilled  by 
the  cold,  be  this  by  its  inherent  properties,  or  by  the  influence 
of  the  terminal  fibril  Ise  of  the  nervous  system,  the  mucous  mem- 
brane no  longer  absorbs  this  halitus  of  the  breath,  and  a  portion  - 
of  this  moisture  accumulates  for  a  while  in  the  tissue  of 
the  mucous  membrane  or  just  beneath  it,  giving  rise  to  the 
sense  of  puffiness  or  fulness  so  familiar  to  all  who  have 
suffered  from  this  complaint.  After  a  while  these  tissues 
become  saturated  and  will  take  up  no  more  fluid,  and  a  process 
of  exosmosis  is  set  up  by  which  the  watery  constituents  of  the 
fluids  coursing  in  its  tissue  are  directed  towards  the  surface, 
and  drip  from  the  nostrils,  constituting  the  characteristic 
discharge  of  coryza,  which  is  at  first  mere  water,  the  exhalation 
of  the  moisture  in  the  expired  breath.  When  this  exhalation 
is  exhausted,  the  water  is  derived  from  the  contents  of  the  blood- 
vessels, and  then  we  find  the  secretion  to  contain  some  of  the 
saline  constituents  of  the  blood.  These  saline  particles  irritate 
the  inflamed  mucous  membrane,  and  finally  excoriate  its  sur- 
face, as  well  as  the  surface  of  the  skin  of  the  nostrils  and  upper 
lip  in  some  instances,  and  keep  up  a  disposition  to  sneeze,  and  a 
necessity  for  the  fi-equent  use  of  the  handkerchief,  the  mechan- 
ical  effect   of  which,  as  well  as  the  irritating  nature  of    the 


254      AFFECTIONS  OF  THE  NASAL  PASSAGES. 

secretion,  inflames  the  exterior  of  the  nose  and  the  cheeks,  as 
well  as  the  margins  of  the  nostrils  and  the  surface  of  the  lip. 

At  a  later  stage  of  the  complaint,  mncus  appears  in  the 
secretion,  and  finally  more  or  less  pus ;  and  the  secretion  is 
thickened,  whitish,  yellowish,  or  greenish  in  color,  according  to 
the  intensity  of  the  inflammatory  action ;  being  often  attended  by 
a  faint,  unpleasant  odor,  which  sometimes  increases  to  absolute 
fetor.  The  entire  secretion  is  not  always  discharged.  Portions 
concrete  into  crusts,  which  are  removed  by  the  handkerchief,  by 
the  finger-nail,  or  by  hawking  and  nasal  screatus. 

The  usual  duration  of  an  attack  of  acute  coryza  is  from  f onr 
to  seven  days ;  occasionally  it  lasts  but  two  or  three  days ; 
sometimes  it  continues  a  fortnight,  a  month,  or  even  longer;  a 
fresh  attack  seeming  to  supervene  upon  one  which  is  about  sub- 
siding. In  some  instances  these  attacks  follow  after  each 
other,  with  intervals  of  complete  subsidence  of  two  or  three 
days'  duration.  Sometimes  one  side  is  attacked  after  the 
disease  has  subsided  npon  the  other ;  and  there  may  be  a  pro- 
tracted alternation  of  this  kind. 

The  nsnal  termination  of  an  attack  of  acute  coryza  is 
by  resolution,  i-arely  by  suppuration.  Sometimes  it  declines 
into  the  chronic  form  of  the  complaint,  though  this  is  more 
fi-equently  a  result  of  repeated  attacks  in  more  or  less  rapid 
succession.  Sometimes  it  leaves  a  permanent  obstruction 
in  the  lachrymal  duct ;  sometimes  a  permanent  obstruction  in 
the  Eustachian  tube  ;  sometimes  a  permanent  obstruction  of  the 
passage  into  the  frontal  or  maxillary  sinus,  leading  to  chronic 
diseases  of  these  parts,  which  may  eventuate  in  caries,  in  drojDsy, 
in  abscess,  in  the  production  of  a  morbid  growth.  'Not  infre- 
quently it  seems  to  be  the  starting-point  for  the  production  of 
nasal  polyps. 

The  principal  cause  of  ordinary  coryza  is  sudden  exposure  to 
cold  when  over-heated,  or  exposure  to  undue  heat  when  the 
body  has  become  chilled.  Sometimes  it  is  due  to  the  inhalation 
of  irritating  dust  and  vapors  to  which  the  subjects  are  exposed, 
either  accidentally  or  in  the  course  of  their  ordinary  avocations. 

It  is  not  contagious,  though  it  has  sometimes  been  thought  to 
be  so ;  but  experiments  have  been  made  by  various  observers 


COEYZA.  20D 

who  liave  placed  the  secretions  of  coryza  in  contact  with  their 
own  pituitary  membrane  without  any  induction  of  the  affection. 

Some  children  seem  to  be  subject  to  catarrh  of  the  nasal 
passages,  chronic  in  character,  from  their  very  birth,  and  often  in- 
volving the  bronchise  simultaneously,  or  shortly  after ;  so  that  it 
may  almost  be  said  that  they  are  born  with  a  chronic  coryza. 
Accessions  occur,  attended  with  profuse  secretion  from  the  mu- 
cous membi-anes  ;  the  nose  becomes  stopped  up,  and  the  patient 
breathes  with  the  mouth  open.  There  is  snoring,  but  no  dys- 
pnoea. The  disease  is  sometimes  fatal.  Politzer  mentions  a  case 
which  led  by  its  long  duration  to  an  arrest  in  the  development 
of  the  thorax. 

The  syphilitic  coryza  of  children  has  been  alluded  to 
incidentally  in  the  article  on  syphilitic  sore  throats  in  infants. 

A  case  of  coryza  can  often  be  aborted,  if  appropriate  treat- 
ment for  that  purpose  be  instituted  within  the  first  twelve  or 
twenty -four  liours  of  the  attack.  A  moderately  large  dose  of 
opium  or  of  alcohol,  sufficient  to  excite  the  stimulant  properties 
of  the  drug,  inducing  sleep,  but  falling  short  of  narcotism,  will 
often  put  an  end  to  the  affection  at  once.  Such  a  dose  would 
be,  on  an  average,  from  a  grain  to  a  grain  and  a  half  of  opium, 
or  its  equivalent  in  solution,  or  from  one-fourth  to  one-third  of 
a  grain  of  a  salt  of  morphia,  preferably,  perhaps,  the  muriate. 
The  alcoholic  dose  would  depend  much  on  the  habits  of  the  in- 
dividual. For  one  unaccustomed  to  liquor,  a  wineglassful 
of  good  whiskey  or  brandy  in  a  gobletful  of  warm  water, 
with  a  small  slice  of  lemon-peel,  and  made  palatable  with  sugar 
dissolved  in  the  water  before  the  addition  of  the  alcohol,  will 
usually  answer  the  purpose.  These  doses  should  be  taken  on 
going  to  bed,  just  before  which  time  it  may  be  well  to  place  the 
feet  and  legs  for  a  few  moments  in  a  hot  bath  made  somewhat 
stimulatiug  by  the  introduction  of  a  handful  or  two  of  ground 
mustard.  If  the  disease  has  come  on  towards  the  middle  or 
latter  part  of  the  day,  one  or  other  of  these  plans  will  prove 
successful  in  very  many  instances.  Other  remedies  recom- 
mended in  a  similar  manner  are  :  carbonate  of  ammonia,  10  grs. 
at  bed-time ;  muriate  of  ammonia,  20  to  30  grs.  at  bed-time ; 


256  AFFECTIONS    OF    THE    NASAL    PASSAGES. 

ffuaiac  in  tincture,  a  drachm  or  so  in  a  wineg-lassf  ul  of  warm 
milk.  The  inhalation  of  chloroform  to  the  induction  of  anses- 
thesia,  administered  after  the  patient  has  been  put  into  bed,  will 
often  be  found  adequate  to  abort  a  cold  by  its  relaxing  influ- 
ence upon  the  structures,  which  are  in  a  state  of  tension.  Per- 
sonal experience  has  proven  the  value  of  this  remedy  in  a  num- 
ber of  instances,  especially  in  such  as  were  thought  too  far  ad- 
vanced to  promise  success  in  the  abortive  treatment  by  opium 
or  alcohol.  But  while  the  use  of  the  anaesthetic  is  acknowl- 
edged to  be  efficient  for  the  purpose,  the  responsibility  of  a 
resort  to  it  must  rest  upon  the  physician  prescribing  it.  It  is, 
in  some  respects,  a  dangerous  remedy,  and  one  to  be  employed 
in  skilful  and  careful  hands  only ;  and  therefore  not  to  be 
generally  recommended.  But  such  happy  effects  have  followed 
its  use  in  the  author's  hands  in  some  cases  attended  by  intense 
pain  and  tension  in  the  frontal  and  maxillary  region,  and  pre- 
senting distressful  obstruction  to  breathing,  that  an  acknowledg- 
ment of  its  value  is  not  to  be  withheld.  The  cases  alluded  to 
would  have  required  larger  doses  of  narcotics  to  control  their 
symptoms  than  it  was  deemed  desirable  to  prescribe ;  and  the 
fact  was  remembered  that  the  administration  of  chloroform  for 
the  relief  of  pain  already  existing,  is  by  no  means  attended 
with  anything  like  the  same  danger  as  when  it  is  given  for  the 
prevention  of  pain.  An  examination  into  the  statistics  of 
deaths  from  chloroform  will  show  that  this  result  rarely  hap- 
pens when  it  is  judicially  administered  for  the  relief  of  pain, 
as  in  neuralgia,  parturition,  and  operations  begun  without  resort 
to  anaesthesia. 

When  the  cold  has  existed  all  day,  or  has  existed  for  twenty- 
four  hours,  it  cannot  be  so  readily  aborted.  But  it  can  often 
still  be  brought  to  a  very  rapid  conclusion  by  producing  a 
state  of  diaphoresis.  This  may  be  done  by  the  administration 
of  diaphoretic  medicines,  such  as  the  Dover's  powder,  nitrate 
of  potassa,  and  the  like,  assisted  by  the  copious  use  of  warm 
drinks,  which  may  be  slightly  medicated  in  the  form  of  weak 
infusions  of  chamomile,  eupatorium,  hops,  and  the  like.  But 
a  very  excellent  plan,  and  one  which  has  borne  the  test  of 
personal  experience,  is  the  use  of  a  warm  air  bath.     This  is 


COEYZA.  257 

produced  by  placing  burning  alcohol,  either  in  a  large  lamp 
or  in  a  saucer,  under  a  chair  occupied  by  the  patient,  whose 
naked  body  should  be  enveloped,  from  the  neck  downwards, 
in  a  blanket  reaching  nearly  to  the  floor;  the  feet  being 
covered  with  woollen  stockings.  The  warm  air  confined  to 
the  body  induces  a  copious  perspiration  of  the  skin,  and 
when  this  has  continued  as  long  as  may  be  desirable,  ten  or 
fifteen  minutes  being  long  enough  as  a  rule,  the  patient  is  put 
to  bed  without  removing  his  blanket.  The  action  of  the  skin 
continues,  and  excites  thirst,  which  may  be  freely  relieved  by 
copious  draughts  of  water,  a  pitcherf  ul  of  which  had  better  be 
placed  at  the  bed-side  for  that  purpose.  Finally  a  deep  sweet 
sleep  sets  in,  and  the  patient  awakes  in  the  morning  well.  He 
should  keep  his  bed  till  towards  the  middle  of  the  day,  and  be 
exceedingly  careful  against  exposure  to  cold,  which  will  be 
very  apt  to  bring  on  a  return  of  the  complaint. 

Where  there  is  little  or  no  general  distress,  but  merely  a 
stuffed  feeling  in  the  nose,  the  inhalation  of  the  vapor  of  ioduie, 
kept  up  more  or  less  continuously  for  two  or  three  hours,  will 
often  suffice  to  cure  the  cold  in  that  time.  The  best  plan  is  to 
place  two  or  three  crystals  of  pure  iodine  in  a  tube,  and  for 
this  purpose  a  quill  will  answer,  and  to  keep  this  iodine  in  the 
centre  of  the  tube  by  m.eans  of  a  light  cotton  wad  on  both  sides 
of  it.  The  tube  is  held  in  the  hand,  and  one  end  of  it  is  placed 
in  the  nostril ;  the  warmth  of  the  hand  disengages  the  vapor, 
which  is  snuffed  up  from  time  to  time ;  when  the  vapor  irri- 
tates too  much,  the  tube  is  withdrawn  for  a  few  moments  and 
then  re-inserted.  In  this  way  the  inhalation  is  alternated 
between  the  two  nostrils,  if  both  be  affected,  the  patient  placing 
himself  in  any  convenient  position,  recumbent  or  semi-recum- 
bent, and,  if  he  likes,  whiling  the  time  by  perusing  an  enter- 
taining book.  The  iodine  induces  the  flow  of  serum,  which 
relieves  the  distention,  and  probably  exerts  some  beneficial 
action  upon  the  nerves  of  the  affected  membrane. 

Camphor,  or  camphor  and  iodine,  used  in  the  same  way,  has 
been  found  useful ;  as  also  the  use  of  the  muriate  of  ammonia, 
either  produced  in  the  nascent  state  from  muriatic  acid  and  strong 
liquor-ammonia,  or  from  the  fumes  of  heated  sal-ammoniac. 
17 


258  AFFECTIOJSrS    OF    THE    NASAL    PASSAGES. 

The  fumes  of  burning  opium  have  often  been  employed 
successfully  to  abort  or  abate  a  cold  in  the  head. 

An  ingenious  instrument,  devised  by  Dr.  Buttles,  of  JSTew 

Fig.  49.  York,  for  the  inhalation  or  propulsion 

of  vapors  into  the  nostrils,  is  shown  in 

Fig.  49.    It  consists  of  a  glass  receiver, 

into  whi(jh  a  sponge  or  cotton  wad  is 

placed,  saturated   with   the  material 

Buttles' Nasal  Inhaler.  from  which  tlic  vapor  is  to  bc  pro- 

duced.     The  pointed  extremity  is  placed  into  the  nostril,  and 

the  vapor  simply  inhaled,  or  else  propelled  by  passing  a  current 

of  air  through  a  tube  attached  to  the  nozzle. 

Wlien  the  coryza  has  become  fully  established,  we  resort  to  the 
nse  of  warm  aromatic  drinks,  warm  foot-baths,  and  other  me- 
thods of  maintaining  a  gentle  condition  of  diaphoresis  until  the 
affection  is  at  its  height,  when  it  gradually  subsides,  and  the 
employment  of  remedies  is  no  longer  indicated.  If  there  are 
severe  general  symptoms  of  fever,  pain,  and  sleeplessness,  these 
are  combated  by  antiphlogistics,  anodynes,  and  hypnotics. 

IDIOSTNCKATIC  COEYZA. 

Hay  asthma  is  one,  and  hay-fever  another  of  the  principal 
terms  used  to  designate  a  peculiar  form  of  periodical  coryza  to 
which  certain  people  are  subject.  It  is  usually  produced  by 
inhalation  of  the  pollen  of  certain  grasses  or  flowers,  and  is  due 
to  a  peculiar  idiosyncrasy  of  the  individual  affected.  It  is 
analogous  to  the  cold  in  the  head  produced  in  some  people  by 
the  proximity  of  powdered  ipecacuanha.  It  is  usually  produced 
by  the  hay  made  from  the  early  grasses.  It  is  sometimes  pro- 
duced by  the  emanation  from  the  rose.  I  know  one  individual 
in  this  city,  an  old  gentleman,  in  whom  an  exceedingly  dis- 
tressing attack  of  coryza,  with  swelling  of  the  nostrils,  lips, 
and  face,  lasting  for  several  days,  is  produced  by  the  powder 
of  the  chamomile  flower.  Persons  thus  affected  periodically 
in  this  way  can  almost  always  antedate  the  onset  of  the  exj^ected 
attack  with  a  wonderful  accuracy,  which  cannot  be  altogether 
explained  by  reference  to  the  ostensible  cause.  Sometimes  the 
nostrils  chiefly  are  affected,  and  sometimes  the  entire  broncliial 


IDIOSYNCRATIC    CORYZA.  259 

tract  also.  The  affection  usually  lasts  for  several  weeks,  but 
can  often  be  arrested  or  prevented  by  a  change  of  locality. 
Quite  recently,  that  is  to  say,  within  two  or  three  years,  it  occur- 
red to  Prof.  Helmholz,  who  had  long  been  subject  to  this  hay 
fever,  to  examine  the  secretions  from  his  nostrils,  and  he  dis- 
covered that  they  contained  vibriones.  He  used  a  weak  solu- 
tion of  the  muriate  of  quinia  (1  part  to  100)  by  injection  with 
relief,  and  was  enabled  to  prevent  the  attack  the  year  following 
by  resorting  to  this  local  treatment  before  the  usual  date  of  its 
occurrence. 

A  similar  affection  is  sometimes  produced  by  emanations  from 
animal  as  well  as  from  vegetable  matters.  Dr.  H.  Charlton 
Bastian  has  recently  restated '  that  he  has  had  frequent  personal 
experience  of  the  fact  that  a  spasmodic  and  catarrhal  affection, 
somewhat  resembling  hay-fever,  may  be  produced  by  emanations 
from  certain  nematoid  worms,  even  after  they  had  been  pre- 
served for  two  or  three  years  in  spirits  of  wine,  and  macerated 
for  a  time  in  calcic  chloride. 

The  treatment  of  an  attack  of  idiosyncratic  coryza  would  not 
differ  from  that  of  the  ordinary  form  of  the  affection  except  in 
temporary  change  of  locality,  or  the  local  use  of  some  agent 
calculated  to  destroy  the  vegetable  emanations  which  give  rise 
to  the  disease.  For  the  latter  purpose,  carbolic  acid  and  sul- 
phurous acid  may  be  employed,  or  the  injection  of  quinine,  as  in 
the  case  above  mentioned.  A  liberal  regimen  and  vegetable 
tonics  are  often  indicated. 

Some  persons  lose  their  susceptibility  to  this  affection  with 
advancing!;  aoje,  but  I  have  been  consulted  in  one  case  where  it 
has  continued  i-egularly  in  a  patient  nearly  ninety  years  old. 

rNFLUENZA. 

Influenza  is  the  name  given  to  an  epidemic  febrile  catarrh 
which  occurs  from  time  to  time,  at  irregular  intervals.  When 
ordinary  coryza  is  more  prevalent  than  usual,  the  term  influ- 
enza is  often  applied  to  it,  but  incorrectly.  The  epidemic  usu- 
ally lasts  about   six  weeks,  and  sometimes  attacks  almost  the 

1  Introductory  Address ;  Brit.  Med.  Jour..,  Oct.  7,  1871,  p.  404,  note. 


260  AFFECTIONS    OF    THE    NASAL    PASSAGES. 

entire  population  of  the  district,  especially  those  exposed  to  the 
inclemencies  of  the  weather. 

The  following  account  of  the  aifection  is  taken  from  the 
concluding  remarks  in  Dr.  Theophilus  Thompson's  "Annals  of 
Influenza."  ' 

"  One  of  the  most  remarkable  circumstances  impressed  on 
our  notice,  is  the  great  similarity  of  symptoms  presented  by  the 
disease  in  its  different  visitations,  notwithstanding  every  diver- 
sity of  season  and  place.  The  complaint  usually  commences 
like  a  feverish  attack,  with  a  feeling  of  chilliness  and  sensation 
as  of  cold  water  running  down  the  back,  weariness  and  stiffness 
of  the  limbs,  and  pains  in  the  neck,  back,  and  loins,  more  in- 
tense than  those  which  attend  the  common  forms  of  fever.  In 
the  more  severe  cases  there  is  decided  rigor,  alternating  with 
heat  and  flushing  of  the  skin;  the  fever  has  an  exacerbation 
every  evening,  and  lasts  from  two  to  fourteen  days.  Pain  is 
often  felt  over  the  frontal  sinuses  and  cheek  bones,  or  behind 
the  sternum ;  the  eyes  are  suffused  ;  there  is  sneezing,  tingling, 
and  an  acrid  discharge  from  the  nostrils ;  a  short,  frequent, 
harassing  cough ;  a  feeling  of  constriction  of  the  chest  and 
throat,  and  not  unfrequently  soreness,  redness,  and  tenderness  of 
the  fauces.  The  inflammation  of  the  tonsils  is  occasionally  in- 
termittent. The  expectoration,  at  flrst  scanty  and  difficult,  con- 
sisting of  thick  viscid  mucus,  usually  devoid  of  air-bubbles,  sub- 
sequently becomes  opaque,  copious,  and  muco-purulent.  Sono- 
rous, mucous,  and  sibilous  ronchi  may  be  detected  by  ausculta- 
tion; and  there  is  frequently  partial  crepitation,  which  is  most 
apt  to  occur  at  the  lower  portion  of  the  lungs.  The  circulating 
system  is  depressed,  the  pulse  being  usually  feeble,  soft,  and 
quick  in  the  early  stages ;  in  the  decline  of  the  disease,  slow, 
and  sometimes  intermitting.  The  appetite  is  impaired,  and  the 
taste  perverted ;  nausea  and  vomiting  are  often  present ;  the 
tongue  white  and  moist,  covered  with  a  creamy  mucus,  or  loaded 
with  a  coating  of  moist  yellowish  fur,  and  presenting  elevated 
papillae  of  a  peculiar  vivid,  red  color  at  the  edges.     In  some 

'  Annals  of  Influenza,  or  Epidemic  Catarrhal  Fever  in  Great  Britain,  from 
1510  to  1837.     Sydenham  So.  Pub.     London,  1853. 


INFLUEIS^ZA.  261 

cases  it  is,  however,  little  affected.  In  most  instances  the  nrine 
is  scanty  and  high-colored,  soon  becoming  thick  and  reddish, 
or  assuming  a  whey-like  appearance,  and  depositing  a  copious 
pink  or  whitish  sediment.  The  depression  of  strength  is  ex- 
treme, occasionally  resembling  the  collapse  of  cholera ;  the 
nsnal  energies  are  subdued,  and  agonizing  fears  of  death  are 
sometimes  present.  The  skin,  at  first  hot  and  dry,  soon  becomes 
perspiring,  and  often  exhales  a  peculiar  flat,  musty  smell ;  some- 
times it  assumes  a  bluish  hue.  When  the  lungs  are  not  mate- 
rially affected,  the  force  of  the  morbid  influence  is  in  some  in- 
stances directed  to  the  bowels,  producing  pain  and  tenderness 
of  abdomen,  and  diarrhoea,  with  mucous  or  dysenteric  evacua- 
tions ;  at  other  times,  the  brain  being  chiefly  involved,  vertigo, 
sleeplessness,  and  delirium  are  prominent  symptoms. 

"In  very  old  and  debilitated  subjects,  the  disorder  often  pre- 
sents the  character  of  suffocative  catarrh.  Amongst  the  most 
characteristic  phenomena  may  be  mentioned  the  persistence 
of  cough  and  debility,  long  after  the  cessation  of  the  other 
symptoms. 

"  The  most  frequent  and  important  complications  are :  inflam- 
mation of  the  bronchial  tubes,  lungs,  pleura,  or  of  the  brain  and 
its  membranes  ;  acute  articular  rheumatism ;  neuralgia  ;  and 
cutaneous  eruptions ;  the  nature  of  the  complication  depending 
on  constitutional  peculiarities,  or  on  exposure  to  the  exciting 
causes  of  the  associated  diseased  action,  about  the  time  of  the 
onset  of  the  attack  of  influenza.  The  principal  varieties  of  the 
complaint  may  be  divided  into — 1st.  The  cerebral ;  characterized 
by  vertigo,  delirium,  erysipelatous  eruption  on  the  face,  some- 
times swelling  of  the  parotid  glands.  2dly.  Guttural ;  at- 
tended with  cynanche  tonsillaris.  3dly.  Bronchial ;  with  difii- 
cult,  oppressed  respiration,  ^thl}'.  Intestinal;  with  diarrhoea, 
mucous  evacuation,  and,  in  some  examples,  tenderness  of 
abdomen.  5thly.  Typhoid.  This  form,  which  rarely  occurs 
except  among  the  poor  and  badly  nourished,  is  characterized  by 
depression  of  pulse,  extreme  prostration  of  strength,  and  other 
symptoms  of  putrid  or  adynamic  fever.  Almost  every  visita- 
tion of  influenza,  although  characterized  by  the  predominance 
of  some  one   variety,  generally  presents  examples  of  each,  be- 


262  AFFECTIONS    OF   THE    ISTASAL    PASSAGES. 

sides    in  some  instances    exhibiting   phenomena    peculiar   to 
itself." 

"  I^othing  can  more  forcibly  prove  the  definite  character  of 
the  influence  which  produces  the  disease,  than  the  similarity  of 
the  symptoms  during  several  centuries,  and  under  snch  different 
degrees  of  civilization." 

The  treatment  for  influenza  would  consist  essentially  in  that 
adopted  for  ordinary  fully  formed  coryza,  with  the  addition 
of  tonic  and  supporting  measures.  There  is  here  a  blood 
poison  at  work,  probably,  as  suggested  by  tlie  late  Prof.  J.  K. 
Mitchell  of  Philadelphia,  of  cryptogamic  origin  ;  and  therefore 
the  direct  employment  of  such  remedies  as  are  inimical  to  these 
organizations  is  indicated.  The  sulphites  and  the  bisulphites, 
or  the  hyposulphites  of  soda,  lime,  or  ammonia  may  be  employed 
internally  with  this  view  ;  and  the  inhalation  through  nose  and 
bronchi  of  the  dilute  sulphurous  acid  water  would  also  act 
beneficially.  There  is  some  evidence  that  this  view  is  correct, 
in  that  the  maintenance  of  an  eqnable  temperature,  kept  up  in 
the  Masschusetts  General  Hospital  during  an  epidemic  at  Boston, 
did  not  secure  any  immunity  from  the  affection  for  the  inmates 
in  their  wards  ;  and  hence  it  is  fair  to  infer  that  the  malady  is 
due  to  extraneous  matters  in  the  atmosphere.  On  this  view,  the 
treatment  above  indicated  ought  to  be  successful.  The  various 
complications  should  be  met  on  general  principles,  care  being 
taken,  in  combating  evidences  of  inflammation,  not  to  resort  too 
hastily  to  depletion,  especially  by  venesection ;  and  to  be 
equalh"  cautious  about  other  depressing  remedies,  inasmuch  as 
the  disease  is  of  that  tendency  which  we  call  typhoid. 

Quinine  or  bark  in  large  doses  would  be  indicated  as  a  tonic, 
and  distilled  licpiors  and  carbonate  of  ammonia  as  stimulants. 
I  should  think,  in  bronchial  complications  especially,  that  car- 
bonate of  ammonia  in  ten  or  fifteen  grain  doses,  protected  by 
some  bland  mucilage,  repeated  every  two  or  three  hours,  or 
oftener,  would  be  of  great  utility. 

Mild  cases  would  not  require  any  special  treatment  other  than 
that  adopted  for  coryza  of  equal  severity;  but  the  inhalation  of 
sulphurous  acid  water  and  its  injection  into  the  nostrils  would 
be  no  more  amiss  than  in  the  management  of  the  severer  cases. 


CHKOlSriC   COEYZA.  263 

Not  only  are  humau  beings  subject  to  attacks  of  inflnenza,  but 
tlie  lower  animals  also  suffer  from  its  epidemic  influence. 

Influenza,  when  fatal,  is  usually  so  on  account  of  the  pulmo- 
nary or  cerebral  complications.  It  is  said  often  to  leave  debility, 
nervous  prostration,  and  a  susceptibility  to  phthisis,  in  those 
predisposed  to  it.  Dr.  C.  Hanfleld  Jones  mentions '  a  case  in 
which  cerebral  paresis  was  occasioned  by  influenza. 

An  excellent  article^  on  the  subject  of  influenza,  prepared 
chiefly  from  notes  of  cases  which  came  under  his  own  care 
a  few  years  ago,  has  been  written  by  Dr.  Jas.  J.  Levick,  of 
Philadelphia. 

CHEONIC    COEYZA. 

Chronic  coryza,  chronic  nasal  catarrh,  chronic  rhinorrhoea,  as  it 
has  been  variously  called,  is  usually  accompanied  with  an  hyper- 
trophic thickening  of  the  mucous  membrane  covering  the  tur- 
binated bones,  especially  the  lower  ones, — a  condition  which  is 
readily  recognized  on  examination  anteriorly  with  the  speculum. 
Sometimes  the  mucous  membrane  of  the  alse  is  in  a  similar  con- 
dition, producing  circumscribed  protrusions  of  a  red  color,  which 
are  liable  to  be  mistaken  for  fibroid  or  other  growths.  Sometimes 
the  protrusions  are  due  to  obstructions  of  the  orifices  of  the 
glands  of  the  nasal  mucous  membrane.  The  accumulation  of 
secretion  pushes  the  mucous  membrane  before  it,  until  finally 
a  sort  of  exterior  pocket  is  formed,  with  contents  of  greater  or 
less  consistency.  These  are  usually  elastic  to  the  touch,  but 
are  sometimes  cjuite  hard  fi'om  induration.  The  parts  usually 
bleed  freely  on  injury,  but  the  bleeding  is  easily  arrested.  In 
addition  to  this  physical  condition  of  the  mucous  membrane, 
we  occasionally  find  polypous  or  warty  excrescences  here  and 
there,  not  infrequently  upon  the  posterior  portion  of  the  floor 
of  the  nostril. 

The  symptoms  of  chronic  coryza  are  those  of  frequent  or 
permanent  obstruction  of  the  nasal  passages,  with  a  more  or 
less  copious  secretion  of  a  mucous  or  muco-purulent  character, 

'  Studies  on  Nervous  Functional  Disorders.     London,  1870. 
"Remarks  on  the  Epidemic  Influenza  of  1861  and  of  1863,  with  notices  of 
some  malignant  forms  of  the  disease.     Am.  Jour.  Med.  Sci.  1864,  p.  65. 


264  AFFECTIONS    OF    THE    NASAL    PASSAGES. 

discharged  from  the  passages  ^posteriorly  as  well  as  anteriorly. 
This  obstruction  is  usually  greater  in  damp  than  in  dry 
weather;  and  not  infrequently  we  find  that  either  one  passage 
or  the  other  is  nearly  wholly  impervious  to  the  air,  there  being 
no  regularity  with  respect  to  the  nostril  affected.  The  relaxed 
mucous  membrane  absorbs  the  moisture  from  the  atmosphere, 
and  in  this  way  tends  to  occlude  the  ])assage. 

In  simple  cases,  uncomplicated  with  fetor  of  the  secretions, 
there  is  rarely  any  ulceration,  or  even  abrasion,  of  the  mucous 
membrane ;  but  in  severe  cases  this  condition  prevails.  It  is 
described  under  the  head  of  Ozoena. 

The  affection  sometimes  appears  as  a  result  of  repeated  at- 
tacks of  acute  coryza,  but  more  frequently  seems  to  have  com- 
menced in  a  slow  manner,  chronic,  as  it  were,  from  the  outset. 
When  seen  by  the  practitioner  it  has  usually  existed  a  number 
of  months,  or  a  number  of  years,  sometimes  having  included 
almost  the  entire  life  of  the  patient. 

The  subjects  of  this  affection  are  preeminently  those  of 
scrofulous  diathesis,  or  those  afflicted  with  hereditary  syphilis. 

The  treatment  of  chronic  coryza  is  similar  to  that  to  be 
described  for  the  milder  cases  of  ozoena.  Care  must  be  taken 
that  good  hygienic  regulations  be  observed,  as  regards  food, 
diet,  clothing,  cleanliness,  and  exposure. 

Where  there  is  merely  thickening  or  induration  of  the  nasal 
mucous  membrane,  much  benefit  can  often  be  procured  from 
the  local  application  of  the  mineral  astringents,  or  of  nitrate  of 
silver,  carbolic  acid,  etc.  Where  the  membrane  is  much 
relaxed,  or  protruding  into  the  cavity  of  the  nostril,  the  best 
plan  is  to  twist  it  off  with  forceps,  a  very  painful  proceeding ; 
or  to  encircle  it  with  a  wire  snare,  similar  to  that  used  for 
removal  of  aural  polyps,  and  to  cut  it  off  by  drawing  the  loop 
tight,  a  proceeding  much  less  painful.  To  secure  the  action 
of  the  wire,  the  membrane  may  be  drawn  through  it  with  a 
pair  of  delicate  forceps.  The  resulting  sores  may  be  touched 
with  the  nitrate  of  silver.  As  the  edges  of  these  wounds  con- 
tract in  cicatrization,  the  free  space  of  the  nasal  passages  is 
increased.  Many  operations  are  usually  required  to  free  the 
nasal  cavities  from  these  folds  of  mucous  membrane.     In  cases 


CHRONIC    COEYZA.  265 

of  exceeding  obstinacy,  and  whicli  cannot  be  cured  in  this  way, 
freedom  of  nasal  respiration  may  be  secured  by  the  introduction 
of  silver  tubes  through  the  nostrils,  connected  in  front,  so  as  to 
prevent  their  falling  into  the  pharynx.  These  may  be  worn 
every  night,  to  keep  the  nostrils  patulous,  and  to  promote  retrac- 
tion of  tissue  by  the  compression  they  exercise. 

When  the  presence  of  polyps  is  the  cause  of  the  coryza,  their 
removal  is  essential  to  a  cure. 

The  habitual  use  of  the  nasal  douche,  followed  by  the  injec- 
tion of  astringent  solutions,  will  be  of  great  service  to  the 
patient,  and,  if  persisted  in,  often  prevent  any  aggravation  of 
the  affection.     Occasionally  it  will  be  adequate  to  a  cure. 

A  chronic  discharge  from  the  nostril  may  occur  from  reflex 
irritation  elsewhere.  Thus  a  case  is  related'  by  Mr.  Fleisch- 
mann,  of  Wrexham,  of  a  little  girl,  five  years  of  age,  troubled 
for  three  months  with  a  constant  discharge  from  the  nostril, 
slightly  purulent,  but  not  pi'of  use.  The  mucous  membrane,  as 
far  as  it  could  be  examined,  was  healthy,  and  there  were  no 
indications  of  auj  morbid  growth.  She  was  ordered  a  strong 
injection  of  gallic  acid,  and  took  concurrently  small  doses  of 
the  sesquichloride  of  iron.  The  only  advantage  she  derived 
was,  that  the  discharge  lost  its  purulent  character.  In  amount 
it  remained  the  same,  though  the  treatment  was  long  persevered 
in,  and  other  astringents  tried.  Some  undiscovered  local  irri- 
tation was  suspected.  As  nothing  could  be  found  wrong  in  the 
nasal  passages,  the  condition  of  the  teeth  was  examined,  and  as 
there  was  caries  of  the  upper  canine  tooth  of  the  same  side  as 
the  affected  nostril,  it  was  removed.  The  discharge  was  much 
lessened  on  the  next  day,  and,  in  the  course  of  a  day  or  two, 
disappeared  altogether. 

OZCENA. 

Ozoena  is  a  term  which  is  used  to  designate  any  chronic 
discharge,  of  a  fetid  character,  from  the  nasal  passages.  A  dis- 
charge of  this  kind  may  attend  several  different  conditions, 
and  the  term,  therefore,  is  merely  denotive  of  a  characteristic 

1  {Brit.  Med.  Jour.,  Apl.  9,  1859.)     Am.  Jour.  Med.  Scl,  July,  1859,  p.  236. 


266  AFFECTIOKS    OF   THE    NASAL    PASSAGES. 

symptom,  Ozoena  is  present  in  nlcerations  of  the  mucous  mem- 
brane of  the  nasal  passages,  and  of  the  sinuses  communicating 
witli  them,  whether  tlie  result  of  what  is  called  the  strumous 
or  scrofulous  diathesis,  or  whether  the  result  of  syphilitic  ulcer- 
ation, or  of  that  ulceration  dependent  upon  lupus. 

Sometimes,  however,  we  meet  with  a  case  of  chronic  disease 
of  the  nasal  passages  unattended  by  any  evidence  of  dyscrasia 
whatever.  The  bones  and  cartilages,  as  far  as  their  condition 
can  be  determined,  are  healthy,  and  there  may  not  be  any 
ulceration  of  the  mucous  membrane  visible  on  inspection, 
either  anteriorly  or  posteriorly.  The  affection  in  these  cases 
seems  to  depend  on  some  constitutional  idiosyncrasy,  in  conse- 
quence of  which  portions  of  the  nasal  secretions  desiccate,  and 
remain  impacted  in  some  of  the  sinuosities  of  the  nasal  pas- 
sages, and  there  undergo  decomposition.  The  condition  has 
been  compared  to  that  which  is  attended  by  peculiar  oifensive- 
ness  of  the  cutaneous  perspiration  from  the  feet  and  armpits 
of  some  persons  who,  in  spite  of  the  most  scrupulous  ablutions, 
cannot  rid  themselves  of  their  unpleasant  odor.  Be  this  as  it 
may,  there  is  no  doubt  that  cases  of  ozcena  exist,  in  which  we 
can  find  no  adequate  cause  to  account  for  the  affection.  Indi- 
viduals thus  afflicted  are  rendered  very  unhappy  by  reason 
of  their  infirmity,  which  deters  them  from  seeking  the  society 
of  their  friends,  or  resorting  to  places  of  public  gathering ; 
and  the  affliction  is  the  more  severe  that  the  subjects  are  often 
in  excellent  general  health,  and  anxious  and  willing  to  take 
part  in  domestic  and  social  enjoyments.  In  these  cases  the 
discharge  is  not  always  prof use,^ sometimes  it  is  very  scanty; 
but  it  exhibits  a  disposition  to  desiccate  into  thin  scales  or 
crusts,  which  are  removed  with  diificulty,  sometimes  from  the 
nostrils,  and  sometimes  by  a  sort  of  inspiratory  nasal  screatus, 
which,  after  repeated  efforts,  drives  them  through  tlie  posterior 
nares  into  the  pharynx,  whence  they  are  expectorated.  These 
crusts  have  usually  a  horrible  stench,  which  is  perceptible  at  a 
distance  of  many  feet,  and  may  impregnate  a  large  room. 

All  that  can  be  done  effectually  in  the  way  of  treatment  in 
these  cases  is  to  keep  up  an  active  condition  of  the  secretory 
functions  of  the  skin  and  kidneys,  by  frequent  bathing  and  the 


OZCENA.  267 

copious  drinking  of  water, — a  sort  of  sewerage,  as  it  were ;  and 
to  cleanse  the  parts  thoronglilj  and  eiRciently  several  times  a 
day,  especially  at  night  and  morning ;  making  this  act  a  per- 
manent and  essential  part  of  the  daily  toilet,  as  mnch  so  as  the 
use  of  the  tooth-brush  or  the  wash-basin.  The  nasal  douche  of 
Thudichum,  to  be  presently  described,  is  an  admirable  apparatus 
for  this  purpose ;  but,  if  the  crusts  are  hard  to  remove,  the  use 
of  the  posterior  nasal  syringe,  and  of  the  continuous  rubber 
ball  syringe,  in  such  request  for  ordinary  family  use,  will  afford 
better  results ;  the  latter  especially  in  those  cases  in  which  crusts 
moulded  to  the  form  of  the  posterior  openings  of  the  nares  are 
apt  to  accumulate,  and  which  must  be  dislodged  by  a  stream  of 
some  force  entering  the  nostrils  fi'om  the  fi'ont.  The  ordinary 
solution  of  common  salt,  a  drachm  or  two  to  the  pint  of  tepid 
water,  fulfils  the  requirements  of  the  douche  for  cleansing- 
purposes  ;  and  the  detachment  of  the  crusts  is  facilitated  by 
the  substitution  or  addition,  as  may  prove  most  appropriate,  of 
equal  quantities  of  alkalines,  such  as  carbonate  or  bicarbonate 
of  soda,  phosphate  of  soda,  and  the  like.  At  least  a  quart  of 
the  solution  should  be  used,  at  each  night  and  morning  ablution. 
After  cleansing  the  parts  in  this  way,  a  second  douche  should 
be  used,  containing  a  disinfectant  in  solution.  For  this  purpose 
we  may  employ  the  permanganate  of  potassa,  chlorinated  soda, 
carbolic  acid,  and  so  on,  which  wall  in  great  measure  control 
the  fetid  character  of  the  secretions.  Various  applications  are 
made  at  times  for  the  purpose  of  altering  the  condition  of  the 
mucous  membrane.  These  are  preparations  of  the  bichloride 
of  mercury,  iodine,  the  terebinthinates,  muriate  of  ammonia, 
etc.,  in  the  form  of  powder,  solution,  or  vapor ;  though,  in  my 
own  hands,  they  have  proved  of  very  questionable  benefit. 
Local  cleansing,  with  disinfectant  detergent  douches,  and  the 
maintenance  of  the  cutaneous  and  urinary  secretions  by  appro- 
priate remedies,  have  done  good  service ;  but  their  use  must  be 
constant. 

There  is  a  form  of  ozoena,  attended  with  certain  local 
manifestations,  which  is  ingrafted  upon  the  strmnous  dia- 
thesis ;  and  which  from  its  persistence,  and  from  its  ultimate 
effects,  which,  when  very  severe  and  improperly  attended  to, 


268  AFFECTIONS    OF    THE    ]^ASAL    PASSAGES. 

resemble  so  mucli  the  effects  of  the  analogous  conditions  in 
constitutional  syphilis,  seems  to  lend  great  force  to  the  doctrine 
so  forcibly  taught  in  some  of  our  schools,  that  scrofula  is  but 
a  modification  of  inherited  syphilis,  bearing,  perhaps,  a  rela- 
tionship to  that  protean  diathesis  somewhat  similar  to  that 
which  varicella  bears  to  small-pox. 

These  cases  can  usually  be  traced  to  a  commencement  in 
coryza  or  catarrh,  the  result  of  exposure  to  cold.  The  catarrh 
becomes  chronic,  the  discharge  more  or  less  profuse,  varying  in 
color  and  appearance,  being  now  muco-purulent,  then  purulent, 
sometimes  sanguinolent.  The  discharge  itself  is  exceedingly 
offensive  in  odor,  but  there  is,  in  addition,  a  permanently 
unpleasant  odor  about  the  breath,  so  that  propinquity  to  the 
individual  is  rendered  very  disagreeable.  The  affection  may 
make  its  appearance  at  any  age,  but  is  usually  noticed  for  the 
first  time  about  the  period  of  the  second  dentition.  The 
subjects  which  I  have  myself  seen  have  been  j)i'iii<iipally 
young  girls  from  six  or  eight  j'ears  of  age  upwards  to  the 
period  of  confirmed  puberty,  or  early  adult  life.  In  these 
cases,  crusts  of  inspissated  mucus  accumulate  at  the  entrance  of 
the  posterior  nares,  from  detention  there  of  the  secretions, 
and  they  often  become  moulded  to  the  form  of  the  opening,  and 
when  discharged  present  a  peculiar  honey-comb  appearance. 
These  moulds  are  usually  several  days  concreting,  and  the 
patient  will  perhaps  discharge  them  once  or  twice  a  week, — 
sometimes  oftener,  sometimes  less  frequent^.  Under  the 
latter  circumstance,  small  dense  clumps  of  irregular  formation 
will  be  occasionally  drawn  into  the  throat  by  forced  nasal 
inspiration,  and  then  spit  out.  These  will  possess  the  char- 
acteristic odor.  Sometimes  small  cheesy-like  concretions 
will  be  discharged,  apparently  from  the  glandular  tissue  at  the 
nasal  portion  of  the  pharyngeal  vault,  similar  to  the  matter 
occasionally  discharged  from  the  tonsils,  and,  like  them,  of  an 
intolerable  stench  when  crushed.  There  will  be  considerable 
pain  in  the  parts,  which  will  be  apt  to  be  particularly  sevei-e  in 
the  region  of  the  frontal  sinuses. 

The  affection  is  met  with  in  all  classes  of  society  ;  in  the 
robust  individual  no  less  than  in  the  delicate  one ;  in  those 


oz(E]srA.  269 

that   are   tenderly   reared,   and   in  those  who  are  allowed  to 
"  rough  it." 

If,  after  thorough  cleansing  with  the  douche,  the  parts  are 
carefully  examined,  anteriorly  by  the  nasal  forceps  or  dilating 
speculum,  and  posteriorly  by  the  rhinoscope,  there  will  usually 
be  discovered  some  points  of  ulceration  of  the  mucous  mem- 
brane, superfical  or  deep-seated.  These  ulcerated  spots  may 
occupy  the  fi-ee  surface  of  the  turbinated  bones,  or  the  lower 
region  of  the  septum ;  and  when  they  cannot  be  found  in  these 
situations,  it  is  fair  to  infer  that  they  must  exist  upon  some 
portions  of  the  turbinated  bones  altogether  out  of  the  field  of 
vision.  The  mucous  membrane  of  the  nose  in  these  instances 
will  be  swollen  so  that  the  opposite  surfaces  of  the  cavity  meet 
at  one  or  more  points,  and  there  will  also  be  sometimes  found 
that  puffy  appearance  of  the  mucous  membrane  covering  the 
inner  surfaces  of  the  septum,  elsewhere  described  as  being 
present  in  other  chronic  affections  of  the  posterior  nasal  region. 
The  swelling  of  the  mucous  membrane  may  be  due  in  most 
instances  to  an  infiltration  of  the  sub-mucous  tissue,  but  in 
some  instances  there  seems  to  be,  in  addition,  a  real  liypertrophy 
of  this  tissue.  The  parts  are  usually  red,  sometimes  very 
sensitive  to  the  touch  of  the  probe,  though  sometimes,  not  at 
all  so. 

If  the  disease  have  existed  for  some  years,  the  ulcerations 
will  have  extended  beyond  the  tissue  proper  of  the  mucous 
membrane,  and  will  have  involved  the  cartilages  and  the 
bones,  portions  of  which  will  sometimes  have  been  destroyed, 
and  have  been  discharged  spontaneously ;  so  that  the  cartilagi- 
nous septum  is  pierced  through  and  through,  sometimes  by  one 
or  two  small  perforations,  but  oftener  in  a  single  large  rounded 
hole,  perhaps  admitting  the  end  of  the  little  finger,  or  a  larger 
one,  and  looking  as  if  it  had  been  cut  out  or  gouged  out.  In 
some  instances  one  of  the  turbinated  bones,  principally  the  mid- 
dle one,  will  be  bare  in  its  entire  extent,  or  the  greater  portion  of 
it,  and  be  in  a  condition  of  necrosis,  demanding  its  extraction ; 
an  operation  readily  accomplished  with  the  polypus  forceps. 
Sometimes,  as  mentioned,  it  has  already  been  removed,  and  left 
a  large  space  in  the  nostril,  through  which  the  posterior  wall  of 


270  AFFECTION'S    OF   THE    NASAL    PASSAGES. 

the  pharynx  or  a  portion  of  the  upper  surface  of  the  velum 
can  be  seen.  In  some  instances  the  destruction  will  have 
proceeded  farther  and  have  involved  portions  of  the  superior 
maxillary  bone,  from  which  copious  accumulations  of  fetid 
pus  and  necrotic  particles  will  have  been  discharged  at  inter- 
vals. In  cases  of  this  kind,  an  alteration  will  have  taken 
place  in  the  external  configuration  of  the  parts,  the  nose 
appearing  sunken,  fallen  in,  or  flattened  out,  and  the  nostrils 
distended. 

In  some  instances  the  openings  of  one  or  more  sinuses  will 
be  found,  the  tracks  of  which  cannot  be  readily  traced,  perhaps 
coursing  round  the  scroll  of  the  turbinated  bones,  but  from 
which,  on  pressure,  a  few  drops  of  thick  creamy  jdus  can  be 
seen  to  exude. 

Usually  some  evidence  or  other  of  a  strumous  taint  of  the 
system  will  be  manifest,  and  this  may  include  every  variety  of 
scrofulous  disease,  from  coxalgia  to  enlarged  tonsils. 

In  cases  of  undoubted  syphilitic  origin, — and  the  distinction 
between  scrofulous  and  syphilitic  ozoena  is  not  always  well- 
marked, — the  involvement  of  the  bony  structures  will  progress 
still  further.  The  palate  bones,  the  sphenoid,  the  vomer,  and  the 
ethmoid,  will  often  undergo  more  or  less  destruction ;  and  in 
some  instances  rhinoscopic  inspection  will  reveal  necrosed  spots 
upon  the  vomer,  the  sphenoid,  and  the  basilar  process  of  tlie  oc- 
cipital bone  ;  a  condition  further  confirmed  by  contact  with  the 
probe.  The  odor  of  the  discharge  in  these  cases  is  not  as 
offensive  as  in  the  scrofulous  cases ;  but  it  is  equally  persistent, 
and  will  remain  as  long  as  there  exists  any  undischarged  dead 
bone.  The  tortuous  condition  of  the  nasal  openings,  and  the 
sinuses  leading  to  them,  is  such  as  to  render  it  impossible  in 
most  instances  to  remove  this  dead  bone  by  surgical  interference, 
and  thus  we  are  forced  to  await  its  discharge  bit  by  bit.  The 
amount  of  destruction  that  may  occur  under  these  circum- 
stances is  enormous.  In  some  instances  the  cranial  vault 
has  been  pierced,  and  meningitis  puts  an  end  to  the  complaint 
and  the  patient. 

The  amount  of  the  discharge,  its  nature,  and  the  intensity  of 
its  odor  will  vary  during  the  progress  of  oza3na,  whatever  may 


OZCENA.  271 

have  been  its  origin.  An  inflammation  of  the  parts,  snch  as  fol- 
lows a  cold,  a  determination  of  blood  to  the  head,  overwork,  the 
approach  of  the  menstrual  period,  all  seem  to  increase  the  offen- 
siveness  of  the  discharge.  This  will  become  moderated  after 
cleansing  by  the  douche,  and  the  application  of  remedies,  but 
will  become  as  bad  as  ever  in  a  few  hours  or  a  few  days. 
When  there  is  involvement  of  the  bone,  or  a  new  involvement 
of  the  bone,  the  fetor  will  be  increased  until  the  necrosed  por- 
tion has  become  exfoliated  and  discharged. 

The  patient,  as  a  usual  thing,  is  cognizant  of  his  unpleasant 
condition  to  a  certain  extent,  but  is  unaware  of  the  full  amount 
of  disagreeable  odor  emitted  from  his  body.  This  is  because 
the  sense  of  smell  is  obtunded,  in  some  instances  entirely 
destroyed;  and  with  it,  in  consequence,  there  is  more  or  less 
loss  of  the  sense  of  taste.  In  those  cases  in  which  the  frontal 
or  maxillary  sinuses  are  affected  to  a  greater  extent  than  the 
nasal  passages,  he  is  better  able  to  appreciate  his  infirmity, 
for  the  sense  of  smell  is  still  conserved  to  a  considerable 
degree. 

The  offensiveness  of  the  odor  in  bad  cases  is  beyond  de- 
scription ;  it  is  absolutely  sickening,  and  must  be  endured  to  be 
comprehended.  It  will  impregnate  a  room  for  hours,  and 
deter  the  surgeon  from  proper  efforts  to  relieve  the  local 
condition. 

Treatment  of  Ozoena. — The  treatment  of  ozoena  is  sufficiently 
simple  in  principle,  but  it  is  exceedingly  tedious  and  unsatis- 
factory in  practice.  Palliation  of  the  severer  symptoms  can 
almost  always  be  procured,  but  a  perfect  cure  often  requires 
months  and  months  of  persistent  treatment,  and  in  some  in- 
stances seems  almost  unattainable,  if  not  quite  so.  Where  the 
larger  bones  are  diseased,  and  where  it  is  impossible  to  get 
thorough  access  to  them,  the  condition  will  last  for  years  and 
years ;  dead  bone  being  exfoliated  splinter  by  splinter,  and  new 
sources  of  evil  becoming  involved  as  the  older  ones  are  under- 
going improvement. 

Fortunately,  in  that  variety  described  as  depending  upon 
an  unfortunate  idiosyncrasy,  the  disease  moderates  in  violence 
as  the  patient  becomes  older,  so  that  in  middle-adult  life  it  has 


272  AFFECTION'S    OF    THE    NASAL    PASSAGES. 

subsided  entirely  or  in  great  measure.  In  the  scrofulous  variety 
we  can  endeavor  to  improve  the  constitution  by  resort  to  sys- 
temic remedies,  such  as  cod-liver  oil,  quinine  and  iron,  the  pre- 
parations of  iodine,  arsenic,  and  so  on ;  and  we  may  thus 
repress  any  increase  of  the  malady,  if  we  cannot  succeed  so 
often  in  restraining  it  altogether.  The  administration  of 
cubebs,  preferably,  perhaps,  in  the  form  of  the  oleo- resin,  in 
doses  of  from  fifteen  to  twenty  drops  or  more  on  sugar,  after 
meals,  will  sometimes  restrain  the  copiousness  of  the  secretions 
to  a  certain  extent,  and  modify  their  character  by  the  local  in- 
fluence of  the  drug  in  its  elimination  through  the  bronchial 
mucous  membrane.  The  decidedly  syphilitic  cases,  when 
they  have  not  progressed  so  far  as  to  be  altogether  irreme- 
diable, are  much  more  manageable  under  systemic  medication 
than  the  idiopathic  or  strumous  forms.  ,  Here,  small  doses 
of  the  bichloride  of  mercury,  with  the  free  use  of  iodide  of 
potassium,  do  as  good  service  as  they  do  in  other  forms  of 
constitutional  syphilis,  especially  if  the  patient  has  retained 
his  vigor.  If  his  general  health  has  become  much  impaired, 
a  course  of  generous  diet,  assisted  by  a  tonic  treatment,  in 
which  the  administration  of  quinine  and  iron  will  do  good 
service,  will  become  necessary  before  any  beneficial  results 
can  be  expected  from  the  specific  treatment. 

Constitutional  treatment,  however,  though  absolutely  essen- 
tial in  the  management  of  this  condition,  is  inadequate  of  itself 
to  a  cure.  Local  treatment  seems  imperatively  demanded  in 
all  forms  of  ozoena. 

This  consists  in  the  frequent  cleansing  of  the  parts,  and  the 
assiduous  application  of  local  remedies.  Without  the  cleansing, 
the  local  remedies  are  of  little  avail ;  they  become  entangled 
with  the  secretions,  and  cannot  have  that  good  effect  upon  the 
parts  which  they  exercise  when  applied  upon  a  clean  surface. 

The  cleansing  process  is  accomplished  by  the  use  of  the  nasal 
douche,  the  posterior  nasal  syringe,  and  the  house  syringe  ap- 
plied anteriorly ;  and  with  the  medicinal  articles  already  enu- 
merated on  page  267.  This  ablution  should  be  attended  to  as 
punctually  and  as  conscientiously  as  the  patient  attends  to  his 
meals,  and  is  on  no  account  to  be  neglected. 


oz(Ei?fA.  273 

The  local  applications  for  remedial  j^urposes  consist  of  solu- 
tions, powders,  and  vapors  drawn  into  the  parts  by  nasal  inspi- 
ration, or  projected  upon  them  by  means  of  appropriate  appa- 
ratus ; — this,  as  far  as  applications  to  the  general  surface  are 
concerned. 

Where  ulcerations  are  seen,  and  where  they  can  be  reached 
by  instruments  introduced  through  the  nostrils,  or  behind  the 
palate,  they  should  be  touched  by  the  sponge,  or  hair-pencil, 
loaded  with  a  solution  of  nitrate  of  silver ;  sulphate  of  zinc  or 
of  copper;  carbolic  acid ;  chromic,  nitric,  or  muriatic  acid ;  or 
of  the  acid  nitrate  of  mercury,  as  the  case  may  seem  to  demand. 
Dead  bone,  where  accessible,  should  be  removed  by  the  forceps, 
assisted,  if  need  be,  by  the  knife  or  scissors.  The  opposite  sur- 
faces of  the  membrane,  when  in  contact,  should  be  kept  asunder 
for  an  hour  or  more  at  a  time  every  day,  by  the  interposition  of 
strips  of  compressed  sponge,  or  tubes  of  laminaria,  which  exercise 
a  compression  upon  the  parts  as  they  imbibe  moisture  from  the 
secretions,  and  thus  favor  the  absorption  of  the  products  of 
submucous  infiltration.  Where  hypertrophied  mucous  mem- 
brane exists,  and  where  internal  compression  is  insufficient  to 
enlarge  the  passage  for  the  free  ingress  and  egress  of  air,  and 
the  free  discharge  of  the  secretions,  it  is  good  practice  to  twist 
off  portions  of  the  membrane  with  delicate  forceps,  so  that  cic- 
atrization of  the  edges  of  the  wound  may  enlarge  the  passage. 
The  free  bleeding  which  accompanies  this  proceeding  exerts  a 
salutary  influence  upon  the  parts  ;  and  though  the  operation  is, 
as  may  well  be  imagined,  an  exceedingly  painful  one  for  the 
patient,  it  is  so  efficient  in  its  relief  that  he  will  readily  undergo 
the  torture,  again  and  again,  for  the  sake  of  the  ease  it  gives  in 
respiration. 

The  solutions  used,  by  douche  or  by  injection,  may  contain 
chlorate  of  potassa,  alum,  creasote  or  carbolic  acid,  permanga- 
nate of  potassa,  chloride  of  lime,  or  similar  articles,  which,  in 
addition  to  their  local  action,  tend  to  control  the  fetor.  Or  we 
may  use  injections  of  nitrate  of  silver,  sulphate  of  zinc  and  cop- 
per, the  sulpho-carbolates  of  zinc  or  lime,  bichloride  or  iodide 
of  mercury,  chloride  of  lime,  chloride  of  zinc,  and  the  like. 
These  injections  should  be  preceded  by  the  use  of  the  douche 
18 


274  affectioj^ts  of  the  nasal  passages. 

for  cleansing  the  surfaces,  and  should  be  employed  at  least 
twice  a  day,  and,  where  practicable,  three  and  even  four  times 
a  day.  They  should  not  be  very  strong  at  first — say  two  grains 
of  the  nitrate  of  silver,  or  sulphate  of  copper  or  zinc,  to  the 
ounce  of  water — and  a  tepid  solution  is  sometimes  better  for 
this  purj^ose  than  a  cold  one,  to  which  end,  tiie  vial  containing 
the  solution  can  be  placed  in  a  warm-water  bath  while  the 
douche  is  being  used  beforehand.  If  the  parts  bear  the  applica- 
tion well,  the  strength  of  the  solution  may  be  gradually  increas- 
ed to  that  of  thirty  and  forty  grains  to  the  ounce ;  care  being 
taken  not  to  make  too  free  use  of  remedies  which  act  promptly 
on  the  constitution,  inasmuch  as  it  is  possible  to  produce  a 
systemic  effect  through  applications  to  the  nasal  membrane, 
owing  to  the  proximity  of  the  olfactory  filaments  to  the  nervous 
centre. 

Indeed,  as  should  have  been  remarked  in  connection  with  the 
treatment  of  idiopathic  ozoena,  we  can  often  relieve  the  pain  in 
the  frontal  region,  promptly  and  efficiently,  by  the  application 
to  the  nasal  passages  of  an  unguent  containing  but  two  or  three 
grains  of  morphia  to  the  ounce,  the  quantity  employed  at  a 
time  being  not  more  than  the  volume  of  a  pea.  This  should 
be  rubbed  into  a  little  wad  of  cotton,  which  may  be  stuck  by 
sealing-wax  upon  the  end  of  a  knitting-needle,  and  passed  along 
the  passages  as  far  as  the  patient  can  reach,  the. ointment  being 
gently  wiped  off  upon  the  parts  as  thoroughly  as  possible,  and 
over  as  great  an  extent  of  surface  as  may  be. 

The  solution  of  the  chloride  of  lime  will  be  found  to  do  good 
service  in  some  obstinate  forms  of  ozoena.  It  was  introduced  in- 
to practice  in  Philadelj^hia  by  the  late  Professor  Horner,^  whose 
plan  was  to  inject  each  nostril  with  a  solution  containing  a  tea- 
spoonful  of  the  chloride  of  lime  in  a  wineglassful  of  water. 
This  was  repeated  twice  a  day.  I  do  not  think  this  practice  is 
much  in  use  at  the  present  day,  but  I  am  sure  it  ought  to  be. 
A  formula^  which  I  have  sometimes  used  with  very  satisfactory 
results,  contains  from  thirty  to  sixty  grains  of  the  chloride  of 

1  Amer.  Jour.  Med.  Science,  vol.  vi.,  1830,  p.  265. 

°  Dr.  Detmold.  of  Hanover  {Holschefs  Annalen,  B.  1804).     Bi^it.  and  For. 
Med.  Bev.,  Oct.,  1841.     Am.  Jour.  Med.  Science.^  Jan.,  1842,  p.  232. 


oz(E]srA.  275 

lime  to  the  ounce  of  a  decoction  of  krameria,  of  which  two  or 
three  drachms  or  more,  dihited  with  an  equal  quantity  of  water,  is 
injected  into  the  nostrils  by  the  patient,  after  the  use  of  the  douche 
night  and  morning.  Sometimes  but  ten  or  twenty  drops  can  be 
employed.  When  the  remedy  excoriates  the  external  parts,  as 
it  will  do  sometimes,  its  use  is  to  be  suspended,  or  its  strength 
reduced,  as  may  seem  to  be  most  judicious. 

The  use  of  glycerine  as  an  injection  is  sometimes  of  great 
service,  particularly  in  the  ozoena  of  a  scrofulous  nature.  It  is 
bland  and  unirritating  in  its  qualities,  has  a  great  affinity  for 
moisture  of  all  kinds,  and  thus  assists  the  removal  of  the  secre- 
tions, inspissated  crusts,  and  detached  fragments  of  dead  bone. 

The  addition  of  iodine  to  the  gljxerine,  in  the  proportion  of 
a  grain  or  two  to  the  ounce,  is  sometimes  advantageous. 

Professor  Trousseau  relied  greatly  upon  certain  medicated 
powders,  of  which  he  directed  the  patients  to  snuff  up  a  pinch 
into  the  nostrils  twice  or  thrice  a  day,  after  having  cleansed 
them  as  thoroughly  as  possible.  He  employed  several  formulas, 
the  principal  of  which  contained  calomel,  and  the  red  precipitate 
mixed  with  sugar ;  the  former  in  the  proportion  of  a  drachm  to 
the  ounce,  and  the  latter  in  the  proportion  of  forty  grains  to  the 
ounce,  care  being  taken  to  regulate  their  use  in  accordance 
with  the  irritation  they  produce.  Another  powder  which  he 
employed  very  frequently,  and  with  great  success,  was  the  sub- 
nitrate  of  bismuth,  rubbed  up  with  Venetian  talc,  in  equal 
parts.  This  was  used  ad  libitum^  and  particularly  recommended 
on  account  of  its  innocuousness.  Powders  containing  cubebs, 
tannin,  camphor,  and  other  ingredients  are  often  used ;  some- 
times they  are  combined  with  snuff.  Since  the  introduction  of 
the  nasal  douche  into  practice,  the  employment  of  powders  is 
less  frecpiently  resorted  to. 

In  some  instances,  citrine  and  other  ointments  are  employed 
locally,  and  may  be  applied  by  a  contrivance  similar  to  that 
described  for  applying  the  anodyne  ointment. 

The.  principal  remedies  used  in  the  form  of  vapor  have  been 
mercurials.  Calomel,  bisulphide  or  binoxide  of  mercury,  are 
evaporated  by  means  of  a  spirit-lamp,  and  the  fumes  are  inhaled 
through  the  nostrils. 


276 


AFFECTIONS    OF    THE    NASAL    PASSAGES. 


Pig.  50. 


Advantage  sometimes  accrues,  in  all  forms  of  chronic  coryza 
and  ozoena,  from  the  free  use  of  the  vapor  of  muriate  of  am- 
monia, following  the  cleansing  of  the  parts  by  the  douche. 
For  this  purpose  the  powder  of  sal-ammoniac  may  be  heated 

over  a  flame  and  the 
fumes  snuifed  up.  The 
most  elegant  method  is 
to  use  the  apparatus  of 
Lewin  (Fig.  50)  for 
generating  the  vapor  of 
muriate  of  ammonia  in 
a  nascent  state.  The 
bottoms  of  two  bottles, 
through  the  corks  of 
which  a  tube  passes  to 
the  bottom,  are  covered 
with  an  ounce  or  so  of 
strong  muriatic  acid  and 
strong  aqua  ammonia, 
respectively;  a  second 
tube,  passing  from  just 
below  the  corks  of  each 
of  these  bottles,  is  car- 
ried do^vn  to  the  bottom  of  a  third,  or  wash-bottle,  half  filled 
with  water.  A  third  tube  from  just  below  the  cork  of  this 
bottle  communicates  with  a  nozzle  to  be  placed  in  the  nostril. 
Air  is  forced  into  the  bottles  containing  the  acid  and  the  am- 
monia, a  hand-ball  bellows,  or  an  air-press,  being  used  for  the 
purpose ;  the  vapors  of  ammonia  and  of  muriatic  acid  are  forced 
into  the  water  of  the  third  bottle,  where  they  unite  to  form  the 
vapor  of  muriate  of  ammonia,  which  escapes  by  the  nozzle  after 
having  been  purified  by  the  water. 

A  few  of  the  author's  cases  are  briefly  recorded  in  illustration 
of  the  value  of  the  douche  of  Thudichum. 


Apparatus  for  generating  nascent  muriate  of  ammonia. 


Ozcena  of  seven  years'  duration. — Martlia  M ,  unmar- 
ried, aged  about  35,  had  been  afliicted  with  ozoena  of  tlie  scro- 
fulous variety  for  several  years.     There  was  no  evidence  of  ul- 


OZCENA.  27T 

I 

ceration  on  examination  of  the  parts,  anteriorly  or  posteriorly. 
This  patient  was  under  treatment  from  April  2Sth  to  June  22d, 
1866,  at  which  date  she  was  discharged  fi-om  professional  attend- 
ance. The  treatment  consisted  in  washing  out  the  parts 
thoroughly  night  and  morning  with  lukewarm  water  containing 
a  tea-spoonful  of  table  salt  to  the  pint,  by  means  of  Thudi  chum's 
nasal  douche ;  and  afterwards  applj^ing  to  the  cleansed  surfaces 
a  solution  of  chlorate  of  potassa  by  the  same  apparatus.  After 
the  second  week  a  weak  solution  of  sulphate  of  zinc  was  substi- 
tuted for  the  chlorate  of  potassa,  alternated  occasionally  with 
a  solution  of  chlorinated  soda,  or  of  permanganate  of  potassa ; 
and  towards  the  last  the  chlorinated  soda  alone  was  used,  in  the 
proportion  of  one  fluid  ounce  of  the  officinal  solution  to  half  a 
pint  of  lukewarm  water.  The  unpleasant  symptoms  had  com- 
pletely subsided  at  the  end  of  two  months,  and  the  patient  was 
dismissed  with  instructions  to  continue  the  use  of  the  nasal 
douche  with  salt  and  water,  as  part  of  her  morning  ablutions. 

Ozoena  of  several  years'  standing  cured  by  persistent 

use  of  the  nasal  douche. — Susan  C ,  about  22  years  of  age, 

first  seen  June  16th,  1866,  had  an  ozcena  of  several  years'  stand- 
ing, following  erysipelas.  There  was  total  loss  of  sense  of  smell, 
even  for  the  most  pungent  and  aromatic  substances.  The  nose 
was  much  altered  in  shape,  and  looked  like  .a  large  rounded 
nodule  of  sausage.  IS^o  signs  of  ulceration.  Five  months'  per- 
sistent use  of  the  nasal  douche  with  astringent  and  detergent 
solutions,  changed  from  time  to  time,  completely  overcame  the 
affection,  with  marked  diminution  in  the  size  of  the  nose,  and 
return  of  smell  so  that  she  could  enjoy  her  food  and  distinguish 
floral  odors.  1  have  seen  this  patient  on  several  occasions  since, 
the  last  but  a  few  months  ago,  and  there  has  been  no  return  of 
the  affection,  although  the  use  of  the  douche  has  been  discon- 
tinued for  nearly  five  years. 

Ozoena  of  twelve  years'  duration,  attributed  to  a  fall. — 

Ellen  S.,  June  26th,  1866,  set.  22,  of  scrofulous  diathesis,  had  a 
moderately  offensive  discharge  from  the  nasal  passages,  which 
she  said  followed  a  fall  received  twelve  years  before,  and  had 


278  AFFECTIOlSrS    OF    THE    ISTASAL    PASSAGES. 

continned  ever  since.  There  was  no  e^^dence  of  deformity  of 
the  nasal  structures.  The  discharge  ceased  under  the  j)ersistent 
use  of  detergents  applied  by  the  douche. 

Ozcenic  discharge  of  a  year's  duration  following  a  blov^r. 

— Frances  K ,  set.  10,  in  March,  1865,  received  a  blow  upon 

the  nose  followed  by  copious  hemorrhage.  Three  days  after- 
wards a  whitish  discharge  came  from  her  nose,  which  had  con- 
tinued until  the  time  at  which  I  first  saw  her,  July  20,  1866. 
This  discharge  was  very  offensive  at  times,  especially  in  rainy 
weather.  The  child  was  of  strumous  diathesis.  Ulcerated  spots 
were  seen  on  the  internal  surfaces  of  the  left  ala  of  the  nostrils. 
The  parts  were  cleansed  daily  by  the  douche ;  and  an  applica- 
tion made  locally  of  an  ointment,  composed  of  one  part  of  the 
ointment  of  the  uiti"ate  of  mercury  to  five  jDarts  of  simple  cerate. 
In  a  few  weeks  the  disease  had  become  entirely  controlled. 

Ozcena  of  nine  yeais'  duration  after  Scarlatina. — Edward 

P ,  set.  14,  had  been  greatly  relieved  when  withdrawn  fi-om 

treatment  by  the  daily  use  of  the  douche,  first  with  salt  and 
warm  water,  and  followed  on  each  occasion  by  warm  water  just 
tinged  pink  by  a  weak  solution  of  permanganate  of  potassa. 

THE   NASAL   DOUCHE. 

Frecjuent  allusion  has  been  made  to  the  nasal  douche  as  a 
means  of  cleansing  the  nasal  cavities,  and  of  applying  to  them 
medicated  solutions.  This  method  of  local  treatment  was  intro- 
duced into  medicine  by  Dr.  Thudichura  of  London,  and  is  a 
great  improvement  on  the  use  of  the  syringe.  It  is  founded  on 
the  fact  discovered  by  Prof.  Weber,  of  Halle,  that  when  we 
breathe  with  the  mouth  open,  so  as  to  cause  the  palate  to  ap- 
pi'oximate  the  pharynx,  we  can  send  a  current  of  fluid  through 
one  nostril  with  the  expectation  of  seeing  it  issue  fi-om  the 
other,  without  the  passage  of  any  of  the  fluid  into  the  mouth. 
The  ordinary  syringe,  or  the  nibber  hand  bellows  syringe  in 
common  use,  may  be  employed  for  this  purpose ;  and  if,  after 
starting  the  latter  insti-ument,  we  simply  raise  the  reservoir  of 


THE    NASAL    DOUCHE. 


279 


fluid  to  a  level  liiglier  than  that  of  the  nozzle,  we  secure  a  con- 
tinuous stream  of  fluid  without  further  pumping. 

A  special  nasal  douche,  however,  has  been  devised  by  Dr. 
Thudichum,  who  gives  the  following  description  of  his  appara- 
tus, of  which  a  representation  is  given  in  flgure  51,  and  of  the 
manner  of  its  emplo^-ment : — 

"  A  rod  of  iron  or  brass,  thirty  inches  in  length,  is  fastened 
"upright  into  a  heavily  loaded  _.        Pig.  si. 

foot,  so  as  to  form  a  firm  stand. 
On  this  rod  slides  a  nut,  which 
can  be  fixed  at  any  height  by 
means  of  a  screw,  and  it  car- 
ries an  arm  and  ring  with  which 
is  connected  a  liigh  cylindrical 
glass  vessel  of  a  capacity  of 
from  one  to  two  pints.  The 
glass  vessel  is  open  above,  and 
its  cavity  contracts  within  the 
ring  in  which  it  is  fastened, 
here  directly  to  pass  into  a 
small-bore  mnzzle,  to  which  a 
suitably  sized  flexible  india- 
rubber  tube,  thirty-six  to  forty 
inches  in  length,  is  fastened. 
To  the  other  end  of  this  india- 
rubber    tube    a  stop-cock   is  fix-     Thudlchum's  nasal  douche  (after  Thudichum). 

ed  ;  and  upon  this  a  little  cup-shaped  collar,  and  upon  this  the 
cylindrical  perforated  nozzle  of  horn  or  of  ebonite  india-rubber. 
If  now  the  glass  vessel  is  filled  with  fluid,  and  the  little  stop-cock 
immediately  underneath  the  nozzle  is  opened,  the  fluid  will  escape 
at  the  fine  openings  of  the  nozzle ;  and  if  the  nozzle  accurately 
fits  the  nostril,  and  the  fluid  is  allowed  to  flow,  the  fluid  will 
enter  and  fill  the  cavity  of  the  nose.' 

"  Great  care  must  be  taken  to  insure  an  adequate  fitting  of 
the  nozzle  to  the  nostril  of  the  person  who  is  to  be  operated 


'  On  Polypus  in  the  Nose,  and  Ozoena  ;  their  successful  treatment  by  new 
methods.     London,  1869. 


280  AFFECTIONS    OF    THE    NASAL    PASSAGES. 

upon,  as,  if  fluid  escape  by  the  side  of  tlie  nozzle,  it  makes  the 
operation  difficult  and  troublesome.  It  is  therefore  necessary  to 
have  several  sizes  of  nozzles,  to  be  fixed  upon  the  stop-cock  at 
will ; — for  adults,  sizes  of  diameters  corresponding  to  the  sizes 
5,  6,  and  7,  of  the  thick  probangs  of  instrument-makers ;  for 
young  persons  and  children,  very  fine  and  more  conical  nozzles 
of  india-rubber,  or  horn.  These  latter  small  nozzles  have  but 
one  central  aperture ;  but  the  large  ebonite  ones  are  provided 
with  four  o];)enings  on  the  convex  part,  for  reasons  which  a  little 
practice  will  show  as  cogent ;  for,  as  the  nozzle  has  to  be  held  in 
an  oblique  position,  one  or  two  openings  are  pressed  against  the 
membranous  septum  of  the  nose  and  closed,  while  at  least  one 
will  be  open  and  sufficient  to  afford  a  good  stream  of  fluid,  two 
or  three  giving  a  considerable  current. 

"In  order  to  avoid  all  possible  chances  of  infection,  and 
insure  cleanliness,  I  lay  it  down  as  a  desideratum,  that  every 
person  using  the  apparatus  should  have  his  or  her  own  nozzle, 
to  be  nsed  exclusively  by  that  person.  In  dispensaries  and 
hospitals,  where  this  cannot  be  so  easily  effected  as  in  private 
practice,  the  utmost  care  should  be  exercised  to  clean  the  nozzles, 
and  particularly  the  little  openings,  from  any  semi-solid  matter 
which  easily  becomes  firmly  adherent  to  them.  As  the  current 
is  always  directed  outwards  through  the  openings,  there  is 
hardly  any  chance  of  the  interior  of  the  nozzle  becoming  un- 
clean or  infectious.  Yet  it  will  be  well  to  give  to  each  patient, 
particularly  if  he  be  the  subject  of  specific  disease,  his  own 
apparatus.  Even  the  suspicion  that  a  j)atient  might,  by  accident, 
blow  into  the  tube  and  endanger  his  successor,  will  thus  be 
avoided. 

"Fluids  to  be  Employed  for  Rinsing. — Pure  warm  water, 
when  introduced  into  the  nose  by  means  of  the  apparatus,  causes, 
in  most  persons,  a  very  disagreeable  sensation,  ending  in  lachry- 
mationand  sternutation  (or  tears  and  sneezing),  with  subsequent 
copious  discharge  of  watery  mucus  from  the  nose.  If  the 
quantity  of  water  run  through  the  nose  be  large,  the 
'  cold '  produced  thereby,  including  tlie  change  in  the  sound  of 
the  voice,  may  last  for  some  hours.    To  avoid  this  objectionable 


THE    NASAL    DOUCHE.  281 

symptom,  it  is  best  to  employ  solutions  of  common  salt,  or  other 
salts,  of  sugar  or  milk,  for  rinsing  the  nose.  In  the  course  of 
practice  cases  will  arise  in  which  all  these  solutions  oft'er  advan- 
tages. For  general  use,  a  solution  containing  a  small  teaspoonf  ul 
of  common  salt  in  a  pint  of  water  is  satisfactory.  Some  persons 
will  bear  less  salt ;  others  will  tolerate  more.  Of  this  solution, 
having  a  temperature  rather  lower  than  that  of  the  blood,  from 
one  to  four,  or,  if  desired,  any  number  of  pints,  may  be  allowed 
to  flow  through  the  cavities  of  the  nose.  It  does  not  easily  pro- 
duce sneezing,  rarely  lachrymation,  and  hardly  ever  any  sub- 
sequent symptom  of  cold  in  the  head.  The  saline  solutions 
which,  next  to  common  salt,  offer  the  greatest  advantages,  are 
those  of  the  common  phosphate  of  soda,  and  phosphate  of  am- 
monia and  soda.  They  can  be  used  by  themselves,  or  mixed 
with  the  common  salt.  Their  alkalinity  has  a  beneficial  effect 
upon  the  irritated  Schneiderian  membrane,  and  dissolves  or 
loosens  any  deposits  of  mucus  or  pus,  which  so  frequently  dry 
and  harden  upon  the  surfaces  of  the  nasal  cavities.  When  these 
solutions  are  made  with  the  common  hot  water  of  kitchen- 
boilers,  they  are  a  little  turbid  from  phosphate  of  lime.  The 
presence  of  this  slight  precipitate  is  no  objection  to  its  use;  on 
the  contrary,  it  is  a  convenient  means  of  distinguishing  this 
from  other  uncolored  solutions  which  may  be  used  at  the  same 
time. 

"  Fluids  to  be  Employed  for  Deodorizing.— For  this  pur- 
pose I  have  employed  dilute  solutions  of  permanganate  of  potash. 
This  agent  has  done  me  such  excellent  service  in  removing  the 
fetor  of  the  mouth  in  cases  of  typhus  fever,  that  I  was  induced 
to  apply  it  for  the  removal  of  the  fetor  of  ozcena,  and  with  the 
most  striking  and  immediate  success.  A  solution  of  from  one 
grain  to  ten  grains  in  a  pint  of  water  is  a  good  proportion, 
according  to  the  severity  of  the  case.  The  solution  taste 
alkaline,  and  acts  as  a  feeble  escharotic  upon  healthy,  and 
particularly  upon  vascular  or  erythematous  parts.  When  the 
margin  of  the  nostrils  is  excoriated,  the  permanganate  colors 
the  excoriated  part  brownish ;  but  the  effect  of  this  is  rather 
beneficial  than  otherwise,  as  the  excoriated  and  colored  part 


2S2       AFFECTIONS  OF  THE  NASAL  PASSAGES. 

dries   easily,  and,  after  tlie   shedding   of   the  faint  brownish 
pellicle,  appears  healthy. 

"  Mode  of  Applying  Fluids. — The  fluid,  of  the  proper  compo- 
sition and  temperature,  is  poured  into  the  glass  vessel.  All  air  in 
the  india-rubber  tube  is  now  replaced  by  fluid,  the  escape  of  the 
air  upwards  being  facilitated  by  gentle  manipulation.  The  glass 
vessel  is  raised  and  fixed  in  the  position  which  will  give  the 
desired  pressure.  A  little  fluid  is  now  allowed  to  escape  from 
the  nozzle,  to  make  sure  that  all  air  is  expelled.  The  patient 
(or  healthy  person,  if  it  is  only  desired  to  show  the  physiological 
experiment)  is  seated  in  front  of  a  basin,  with  his  head  and  face 
slightly  bent  over,  the  apparatus  standing  by  his  side.  He  is  told 
to  breathe  through  his  mouth  exclusively,  and  to  abstain  from 
swallowing.  The  nozzle,  previously  selected  as  of  proper  size, 
and  connected  with  the  apparatus,  is  now  inserted  into  one  of 
the  nostrils,  and  held  there  by  the  patient's  hand  of  the  same 
side.  The  little  stop-cock  is  now  opened,  and  after  a  few 
seconds  a  continuous  and  rapid  stream  of  fluid  is  seen  to  flow 
from  the  opposite  nostril  into  the  basin  below.  Persons  who 
have  control  over  themselves  will  always  bear  the  experiment  as 
here  described ;  but  young  persons,  nervous  females,  and 
children,  become  confused,  begin  to  cry,  or  to  swallow  and 
breathe  through  the  nose.  In  such  cases  the  level  of  the  fluid 
in  the  glass  should  be  very  little  above  the  level  of  the  introitus 
into  the  external  ear,  so  that  the  fluid  runs  very  slowly,  or  only 
drops  out  of  the  free  nostril.  The  hand  of  the  operator  should 
be  upon  the  india-rubber  tube,  to  close  it  by  compression  the 
moment  he  sees  bubbles  come  through  the  nostril,  or  j)erceives 
that  the  patient  swallows  or  becomes  confused. 

"  It  is  always  well  to  let  the  fluid  pass  at  first  under  slight 
pressure,  in  order  to  allow  sordes  within  the  nose  to  be  loosened 
and  crusts  of  dried  matter  to  be  softened.  When  this  has  been 
effected,  it  is  useful  suddenly  to  raise  the  glass  vessel  and  pro- 
duce a  rapid  stream,  which  will  then  scour  the  impurities  away. 
In  some  cases  I  have  done  this  repeatedly  with  success.  The 
loosening  of  crusts  and  lumps  of  inspissated  mucus  is  always 
attended  with  some  irritation,  and  also  with  retardation  and 


THE    NASAL    DOUCHE.  283 

diminution  of  the  current  of  fluid.  The  sudden  increase  of  the 
pressure  is  the  surest  means  of  causing  the  least  inconvenience 
to  the  patient,  and  effecting  in  the  quickest  manner  the  purpose 
of  the  operator, 

"It  is  also  well  to  reverse  the  current  now  and  then,  as  sordes 
are  much  better  detached  in  that  manner.  If  only  one  nostril  is 
diseased,  or  the  principal  seat  of  the  disease,  I  allow  the  fluid  to 
enter  by  the  opposite  side,  and  to  leave  by  the  affected  nostril. 
I  then  change  the  current,  and,  filling  the  affected  nostril,  allow 
the  current  to  leave  by  the  healthy  one.  Thus  half  a  dozen  or 
a  dozen  changes  may  be  usefully  instituted.  This  reversal  has 
sometimes  the  effect  of  throwing  large  lumps  of  insj)issated 
mucus  and  pus  upon  the  upper  side  of  the  soft  palate ;  and  as 
they  are  too  large  to  be  carried  round  the  septum  narium  into 
and  through  the  nasal  canal  by  which  the  fluid  leaves,  they  are 
taken  into  the  pharynx  and  immediately  ejected  by  the  patient 
through  tlie  mouth.  The  presence  of  lumps  upon  tlie  soft 
palate  is,  therefore,  a  cause  of  a  sudden  interruption  of  the 
operation.  After  the  removal  of  these  lumps,  the  operation 
may  be  continued  as  before.  It  is  really  surprising  what  an 
amount  of  sordes  will  sometimes  be  removed  from  the  nose  bv 
the  rinsing  process.  Any  one  who  has  seen  it  once,  will  easily 
conceive  the  manner  in  which,  by  means  of  these  constant  accu- 
mulations, nasal  diseases  become  chronic,  incurable,  and  lead  to 
fearful  suffering  and  death. 

"  Medicinal  Solutions. — Although  the  solutions  before  enu- 
merated act  in  a  measure  as  alteratives,  resolvents  and  escharotics, 
and,  therefore,  rarely  constitute  a  sufHcient  medical- application 
by  themselves,  yet  they  are  more  frequently  used  for  preparing 
the  nose  for  the  application  of  energetic  and  specifically  acting 
solutions.  To  this  latter  class  belong  the  solutions  of  akim, 
sulphate  of  zinc,  and  sulphate  of  copjoer — the  best  astringents  ; 
the  solutions  of  nitrate  of  silver  and  bichloride  of  mercury — 
the  most  suitable  alteratives ;  and  the  solutions  of  chloride  of 
calcium,  in  which  suboxide  or  oxide  of  mercury  is  suspended  in 
a  finely  subdivided  state — the  best  specifics.     Of  stimulating 


284  AFFECTIOlSrS    OF   THE    NASAL    PASSAGES. 

solutions,  a  mixture  of  eau  de  Cologne  with,  water  or  salt  water 
is  sometimes  useful. 

"  The  probable  concentration  of  these  solutions  can  be  sur- 
mised from  the  circumstance  that  the  sensibility  of  the  healthy 
nasal  cavity  stands  about  midway  between  that  of  the  eye  and 
the  mouth.  When  the  nasal  cavity  is  completely  filled  with  fluid, 
the  specific  sense  of  smell  cannot  any  longer  be  exercised  ]  even 
the  solution  of  eau  de  Cologne  is  not  perceived  to  be  such  when 
it  once  fills  the  nose.  The  sense  of  smell  being  thus  entirely 
obliterated  by  the  fiuid  contained  in  the  nose,  the  reflex  effects 
which  substances  may  exercise  by  means  of  this  sense  are 
entirely  absent ;  and  the  only  impingement  which  the  fluids  can 
produce  is  upon  the  filaments  of  sensitive  nerves  coming  from 
the  fifth  pair.  It  is  owing  partly  to  this  circumstance  that 
comparatively  strong  medicinal  solutions  are  borne  by  the  nasal 
cavity  without  great  secretion.  Another  circumstance  favoring 
the  application  of  stronger  solutions  is  the  ready  manner  in 
which  the  healthy  surface  of  the  nose  defends  itself  against 
irritating,  chemically  impinging  substances  by  means  of  a 
copious  flow  of  mucus.  Excoriated  or  ulcerated  parts  lack  this 
power  of  rapid  secretion;  and  hence  they  are  affected  by 
medicinal  solutions  much  more  than  the  healthy  parts  of  the 
surface  of  the  nasal  cavity.  What  is  here  stated  is  the  general 
result  of  experience  and  experiment ;  but,  at  the  same  time,  1 
must  insist  that  the  application  of  medicinal  solutions  in  each 
case  should  be  begun  with  the  greatest  caution,  as  individuals 
differ  greatly  in  point  of  irritability  of  the  nasal  cavity.  In  the 
beginning,  therefore,  very  dilute  solutions  of  medicinal  sub- 
stances should  be  used,  and  their  strength  be  increased  gradu- 
ally, after  their  effect  has  been  well  exhausted,  by  the  use  of 
greater  quantities,  applied  by  a  quick  flow,  or  the  use  of  smaller 
quantities  in  a  slow  current  distributed  over  a  longer  time  of 
contact. 

'*  Solution  of  Alum. — Half  an  ounce  of  roughly-powdered 
crystallized  alum  is  dissolved  in  a  small  quantity  of  hot  water, 
and  the  solution  made  up  to  one  quart  by  means  of  cold  and 
tepid  water  in  such  a  manner  as  to  insure  that  the  temperature 


THE    NASAL    DOUCHE.  285 

of  the  solution  should  be  below,  but  near  to,  blood-heat.  In 
superficial  ulceration  or  blennorrhagic  conditions  this  solution  is 
well  borne.  Ulcerated  parts,  which,  before  its  application,  were 
red,  mostly  appear  as  white  patches  after  its  application,  thus 
showing  that  the  effect  of  the  alum  on  the  ulcerated  surface  has 
been  considerable.  "NVlien  I  was  desirous  to  manage  with 
smaller  quantities  of  solutions,  I  have  sometimes  mixed  a  little 
permanganate  solution  with  that  of  alum. 

"  Solution  of  Sulphate  of  Zinc— From  a  scruple  to  a  drachm 
of  the  sulphate  of  zinc,  dissolved  in  a  quart  of  warm  water, 
together  with  half  an  ounce  of  sulphate  of  soda  or  sulphate 
of  magnesia,  gives  a  suitable  fluid. 

"  Solution  of  Sulphate  of  Copper. — Of  this  sulphate  also 
from  a  scruple  to  a  drachm,  mixed  with  half  an  ounce  of  soda 
sulphate  or  magnesia  sulphate,  can  be  dissolved  in  a  quart  of 
warm  water. 

"  Solution  of  Acetate  of  Lead. — Of  this  crystallized  acetate 
from  a  drachm  to  two  drachms,  together  with  half  an  ounce  of 
crystallized  acetate  of  soda,  may  be  dissolved  in  a  quart  of  warm 
water. 

"Solution  of  Nitrate  of  Silver.— Of  this  salt  not  more  than 
from  half  a  grain  to  a  grain  should  be  dissolved  in  each  ounce 
of  water.  A  quart  of  water,  therefore,  in  which  previously 
from  half  an  ounce  to  an  ounce  of  nitrate  of  soda  has  been  dis- 
solved, may  receive  from  sixteen  to  thirty-two  grains  of  the 
nitrate.  In  particular  cases  the  solution  may  be  made  stronger. 
The  nitrate  of  potash  is  not  so  good  as  the  nitrate  of  soda, 
because  it  has  slightly  irritating  qualities.  When  it  is  neces- 
sary to  use  it  in  an  emergency,  when  soda  nitrate  cannot  be 
had,  the  solution  should  be  more  diluted. 

''  Solution  of  Bichloride  of  Mercury.— The  greatest  caution 
is  necessary  in  the  use  of  this  agent,  as  it  has  a  tendency  to 
produce  excoriations  on  healthy  surfaces.     The  first  solution  to 


286  AFFECTIOISrS    OF   THE    NASAL    PASSAGES. 

be  emplo^'ed  should  be  one  containing  five  grains  of  corrosive 
sublimate  in  a  quart  of  water,  in  v^^hich  an  ounce  of  common 
salt  is  also  dissolved. 

"  Solution  of  Chloride  of  Calcium  -with  suspended  Oxide 
or  Sub-oxide  of  Mercury.— These  fluids  are  the  common 
phagedsenic  waters,  or  black  and  yellow  wash,  to  which  common 
salt  has  been  added.  Two  drachms  of  calomel,  twelve  fluid 
ounces  of  lime-water,  half  an  ounce  of  common  salt,  and  twenty 
ounces  of  warm  water,  yield  the  black  solution.  One  scruple 
of  corrosive  sublimate,  half  an  ounce  of  common  salt,  twelve 
fluid  ounces  of  lime-water,  and  twenty  fluid  ounces  of  common 
warm  water,  yield  the  yellow  wash.  These  mixtures  must  be 
well  agitated  in  the  glass  vessel  while  being  allowed  to  run 
through  the  nasal  cavity. 

"  Sedative  Solutions. — Of  prussic  acid  forty  minims  to  the 
quart  of  warm  salt  water,  of  tincture  of  opium  two  drachms, 
may  be  taken.  These  drugs  may  be  added  to  some  of  the  above 
solutions  of  metallic  salts.  But  if  this  is  desired,  it  is  better  to 
substitute  a  solution  of  morphia  for  tincture  of  opium.  The 
prussic  acid  is  incompatible  with  the  copper,  silver,  and  pre- 
cipitated mercury  solutions ;  it  goes  conveniently  with  the  alum 
and  common  salt  solutions. 

"Styptic  or  Haemostatic  Solutions. — Among  these,  ice- 
cold  salt  water,  containing  an  ounce  of  salt  to  a  pint  of  ice- 
'  water,  takes  the  first  place.  When  this,  after  having  been  con- 
tinued for  a  considerable  time,  is  insufticient  to  stop  the  he- 
morrhage, a  fluid  ounce  of  the  tincture  of  the  sesquichloride  of 
iron  may  be  added  to  each  pint  of  ice-cold  salt  water. 

"Stimulating  Solutions. — One  ounce  of  eau  de  Cologne 
upon  ten  ounces  of  salt  water  is  a  useful  stimulant.  Strong 
spirit  of  wine  may  be  taken  in  place  of  the  eau  de  Cologne. 

"  I  have  now  fully,  and  for  some  readers,  perhaps,  somewhat 
too  explicitly  described  a  number  of  medicinal  solutions  which 
may  with  advantage  be  applied  to  the  treatment  of  nasal  dis- 
eases by  the  method  in  question,  I  was  desirous  to  impress 
upon  the  memory  of  the  reader  the  fact  that  I  recommend  only 


THE    NASAL    DOUCHE. 


287 


such,  solutions  as  are  brought  up  to  a  certain  specific  gravity  by 
salts  which  do  not  decompose  the  medicinal  agents.  There 
may  be  cases  in  which  it  is  desirable  to  swell  the  Schneiderian 
membrane  by  watery  fluid,  and  produce  endosmosis,  and  others 
in  which  highly  concentrated  solutions  may  beneficially  be  used 
to  effect  exosmosis  and  shrivel  Schneider's  membrane.  These 
adaptations,  and  the  various  accommodations  of  the  fluids  and 
their  degrees  of  concentration,  I  must  leave  to  the  skill  and  in- 
genuity of  those  who  make  use  of  this  method.  They  will  also 
probably  multiply  the  resources  of  the  rhino-therapeutic  phar- 
macy, and  thereby  add  to  the  success  and  certainty  of  this  in- 
teresting method  of  treatment." 

Various  modifications  of  this  douche  have  been  made.     Fig. 
52  represents  one  in  very  common  use.     A  bottle  containing  the 

Pig.  52. 


Pig.  53. 


Nasal  Douche. 


Thudichiim's  Syphon  Nasal  Douche. 


fluid  is  held  above  the  head,  or  placed  upon  a  table  higher  than  the 
head,  and  the  current  is  controlled  by  compressing  the  rubber 
tubing  instead  of  turning  a  stop-cock,  as  in  the  more  j)erfect 
instrument.  Fig.  53  represents  a  very  portable  douche,  con- 
trived by  Dr.  Thudichum,  and,  in  fact,  his  original  apparatus. 
It  is  a  flexible  tube  attached  to  a  perforated  metal  weight, 
which  retains  the  apparatus  at  the  bottom  of  a  jug  or  other  vessel 
filled  with  the  fluid.  By  dipping  the  entire  tube  in  the  fluid, 
filling  it  with  fluid  before  immersing  it,  or  by  suction  with  the 
mouth  after  immersion,  or  by  compressing  the  tube  from  the  ves- 
sel towards  the  nozzle,  so  as  to  drive  out  the  air,  the  instrument 
is  converted  into  a  syphon,  and  the  liquid  escapes  very  readily. 
This  is  an  admirable  apparatus  for  patients  wlio  are  travelling. 


288 


AFFECTIOlSrS    OF   THE    KASAL    PASSAGES. 


Finding  difficulty  in  teaching  some  patients  how  to  use  this 
Fig.  54.  syphon,  the  author  modified 

this  douche  several  years  ago 
by  placing  a  compression 
bulb  of  rubber  in  the  course 
of  the  tube,  the  connections 
being  made  by  small  glass 
tubing.  This  form  of  appa- 
ratus is  shown  in  Fig.  S-i.  If 
now  the  bulb  be  compressed 
with  one  hand,  and  the  noz- 
zle occluded  by  the  other,  and 

Syphon  Douche  with  Compression  Bulb.  j-]^q    weight    bc  plaCCd    iu   the 

vessel ;  on  dropping  the  bulb  by  the  side  of  the  jug  and  releas- 
ing the  nozzle  the  syphon  is  made,  and  the  fluid  flows  readily, 


Fig.  55. 


Manner  of  arranging  Syphon  Nasal  Douche. 


as  seen  in  Fig.  55.     In  this  apparatus,  weight,  nozzle,  and  con- 
nections are  all  of  glass,  rendering  the  apparatus  very  cleanly. 


ANOSMIA.  289 

Li  using  the  douche,  tlie  nozzle  is  inserted  into  one  nostril, 
the  sides  of  which  are  compressed  by  the  finger  so  as  to  exclude 
the  air,  and  prevent  the  fluid  from  flowing  back.  The  head  is 
then  bent  well  forward,  the  mouth  opened,  and  the  stream 
allowed  to  flow,  wlien  it  will  all  pass  out  through  the  opposite 
nostril,  provided  there  is  no  occlusion.  In  this  way  masses  of 
accumulated  mucus,  inspissated  secretions,  etc.,  will  be  dis- 
charged. The  process  is  then  repeated  on  the  opposite  side. 
,  Care  must  be  taken  that  the  solution  be  warm,  and  of  a  spe- 
cific gravity  near  that  of  the  blood.  Neglect  of  the  precaution 
to  have  the  solution  warm  has  resulted  in  producing  severe  in- 
flammation of  the  internal  ear,  by  the  passage  of  the  cold  fluid 
along  the  Eustachian  tube,  and  sometimes  serious  disease  has 
ensued,  even  when  every  precaution  enjoined  by  Thudichum 
and  his  followers  has  been  observed ;  as  has  been  recorded  by 
Profs.  Moos,  of  Heidelberg,  and  Knapp  and  Roosa,  of  New 
York,^  and  others.  If  the  solution  be  too  thin,  it  is  apt  to  pro- 
duce a  cold  in  the  head.  For  cleansing  purposes,  a  drachm 
or  two  of  salt  to  the  pint  or  quart  of  warm  water  is  usually 
employed,  and  the  proportion  increased  or  diminished  according 
to  the  efl'ects  which  it  produces. 

Sometimes  the  fluid  enters  the  fi'ontal  sinuses,  producing  in- 
tense pain ;  so  great  in  some  instances  that  the  method  must  be 
abandoned.  So,  also,  must  it  be  abandoned  if  it  produces  symp- 
toms of  disturbance  in  the  auditory  apparatus.  On  this  account 
it  is  well,  in  all  instances,  that  the  first  use  of  the  douche  should 
be  carefully  made  under  the  supervision  of  the  medical  atten- 
dant ;  and  that  its  effects  be  closely  watched. 

ANOSMIA. 

Loss  of  smell  occurs  in  connection  with  various  afi^ections  of 
the  nasal  passages,  from  impressions  made  upon  the  terminal 
distribution  of  the  olfactory  nerves.  Under  these  circumstances 
the  sense  of  smell  usually  returns  to  a  greater  or  less  degree,  as 
the  disease  which  produced  it  is  combated.  Sometimes  the 
sense  of  smell  does  not  return. 

^  Archives  of  Ophthalmology  and  Otology,  Vols.  I. ,  II. ,  III. 
19 


290  AFFECTIOITS    OF    THE    NASAL    PASSAGES. 

Excitation  of  tlie  Schneiderian  membrane  by  the  passage 
along  it  of  the  constant  galvanic  current,  with  interruptions, 
will  sometimes  aronse  this  dormant  sense,  and  the  treatment  by 
electricity  is  therefore  to  be  undertaken  with  confidence.  The 
deprivation  of  this  sense  is  rery  annoying  to  its  subject,  inter- 
fering, among  other  things,  with  the  full  enjoyment  of  food ; 
so  much  of  the  sense  of  taste  being  abolished  as  is  dependent 
upon  the  integrity  of  the  sense  of  smell.  It  is  therefore  our 
duty  to  endeavor  to  excite  the  return  of  smell  by  the  manner 
indicated,  which  appears  to  promise  more  success  than  the  ad- 
ministration of  drugs,  or  the  use  of  topical  applications.  In  the 
author's  hands,  as  in  the  hands  of  others,  electricity  has  some- 
times proved  adequate  for  this  purpose. 

Loss  of  snjell  is  sometimes  dependent  upon  cerebral  disease. 
When  this  is  the  case,  its  return  is  contingent  upon  the  relief  to 
the  trouble  of  central  origin. 

A  case  has  been  recorded  in  which  the  continual  inspiration 
of  the  fumes  of  ether,  accidentally,  in  the  course  of  some  ex- 
periments on  animals,  caused  a  gradual  failure  of  the  sense  of 
smell,  and  at  last  its  total  aberration,  the  effect  being  attributed 
to  the  continuous  contact  of  sulphuric  ether  with  the  minute 
branches  of  the  olfactory  nerve. ^ 

The  most  frequent  cause  of  anosmia,  however,  is  due  to 
blows  received  upon  the  head.  Dr.  William  Ogle  has  recently 
studied  the  subject  of  anosmia^  from  this  cause.  He  reports 
three  cases  in  which  the  sense  of  smell,  and  of  smell  alone,  was 
completely  lost.  Case  1,  of  twenty-seven  years'  standing,  en- 
sued after  a  fall  sustained  upon  the  back  and  side  of  the  head ; 
case  2,  of  two  years'  duration,  from  a  similar  accident ;  and  case 
3,  more  recent,  from  blows  on  the  head  received  in  a  row. 

Dr.  Ogle  attributes  the  loss  of  the  sense  of  smell  in  these  cases 
to  rupture  of  the  olfactory  nerves,  as  they  pass  from  the  bulb 
through  the  perforations  in  the  ethmoid  bone.  lie  maintains 
that  anosmia  of  the  affected  side  is  present  in  every  well-marked 
case  of  facial  palsy.     He  presents  several  cases  of  partial  loss 

1  (Vixchow's  ArcJdv,  IV.  41,  1867),  Syd.  So.  Bie7m.  Hetrofip.,  18G7-8,  p.  84. 
^  Anosmia,  or  Cases  Illustrating  the  Physiology  and  Pathology  of  the  Sense 
of  Smell;  Med.-Chir.  Trans.     London,  1870,  LIII.  p.  263-290. 


ANOSMIA.  291 

of  smell,  and  enters  into  the  physiological  points  of  interest  con- 
cerning olfaction.  His  opinion  is  that  the  external  root  of  the 
olfactory  nerve  is  the  only  one  directly  concerned  in  olfaction ; 
and  that  it  depends  npon  the  degree  in  which  this  root  or  its 
central  termination  has  been  disorganized,  whether  the  loss  of 
smell  be  complete  or  partial.  In  snpport  of  this  view  he  cites 
an  observation  of  M.  Serres,'  made  many  years  ago,  and  founded 
on  the  results  of  nineteen  post-mortem  examinations  of  the 
bodies  of  paralytic  patients,  that  lesion  of  the  external  root  is 
much  more  ethcacious  in  determining  anosmia  than  is  lesion  of 
the  internal  root. 

Dr.  Ilanjilton,  of  Philadelphia,  has  recently  placed  on  record^ 
an  account  of  a  case  of  anosmia  occurring  after  a  blow  received 
npon  the  occiput.  Dr.  Notta  has  also  made  the  subject  of 
anosmia  the  subject  of  a  memoir.' 

Acuteness  of  Smell  is  very  often  serviceable,  especially  in 
giving  warning  of  the  proximity  of  nnpleasant  or  unhealthy 
emanations.  It  also  permits  the  detection  of  certain  diseases 
by  the  odor  of  their  emanations,  and  thus  enters  into  the  field 
of  differential  diagnosis.  The  smells  of  small-pox,  typhus 
fever,  and  other  diseases  are  suihciently  characteristic ;  but  it 
is  maintained  that  the  sense  of  smell  is  adequate  to  the  recoo-ni- 
tion  of  syphilis  ;  and  it  is  recorded''  that  Dr.  Stokes,  of  Dublin, 
as  long  as  thirty  years  ago,  expressed  the  opinion  that  the  nose 
might  be  able  to  detect  the  difference  between  pneumonia  and 
bronchitis.  The  faculty  of  smelling  is  one  to  be  cultivated, 
therefore,  and  to  be  restored  by  therapeutic  means  when  in 
abeyance.  Too  great  an  acuteness  of  smell,  however,  may  be- 
come a  great  source  of  annoyance.  Some  curious  cases  of  this 
kind  are  on  record  in  general  literature  ;  one  of  the  most  remark- 
able of  which  occurred  in  the  person  of  poor  Caspar  ITauser, 
all  of  whose  senses  were'  exquisitely  developed,  so  much  so  as 
to  be  extremely  annoying  to  him  at  times ;  but  the  sense  of 

'  Anat.  Comp.  du  Cerveau,  I.  295. 

*  Am.  Jour.  Med.  Sci.    Apl.,  1871,  p.  41. 

^  Recherches  sur  la  perte  de  I'odorat.  Arch.  Gin.  de  Med.  Apl.,  1870,  pp. 
385-407. 

*  Brit.  Med.  Jour.     March  4,  1871. 


292  AFFECTIOJSrS  oiF    THE    NASAL    PASSAGES. 

smell  was  most  troublesome  to  him,  and  rendered  his  life  miser- 
able. He  perceived  odors  where  others  could  detect  nothing  of 
the  kind.  He  was  over2:)Owered  by  the  fragrance  of  a  rose,  and 
could  distinguish  fruit-trees  from  each  other,  at  a  considerable 
distance,  by  the  odor  of  their  leaves.  The  smell  of  old  cheese 
produced  nausea  and  vomiting  ;  and  that  from  a  churchyard  oc- 
casioned a  paroxysm  of  fever.  The  so-called  perfumes,  em- 
ployed for  cosmetic  pui-poses,  were  more  disagi-eeable  to  him 
tlian  many  of  the  decidedly  unpleasant  smells.  In  fact,  every 
odor,  excepting  those  of  bread,  fennel,  anise,  and  caraway,  was 
more  or  less  disagreeable  to  him,  so  much  so  that  the  only  food 
he  would  partake  of  was  bread  and  water.^ 

SYPHILITIC  AFFECTIONS  OF  THE  NASAL  PASSAGES. 

These  are  sufficiently  common,  and  exist  as  one  of  the  mani- 
festations of  secondary  syphilis.  Under  these  circumstances 
the  disease  appears  confined  to  the  mucous  membrane.  It  is 
usually  attended  l)y  a  chronic  coryza,  the  matters  of  the  dis- 
charge being  viscid  and  of  a  yellowish  or  greenish  color,  some- 
times sanguinolent,  and,  as  a  rule,  more  coj^ious  in  the  daytime 
than  at  night,  perhaps  from  unconscious  deglutition  of  portions 
of  the  discharge  during  Blee^o.  There  is  no  ulceration  of  the 
mucous  membrane  at  first,  but  this  is  almost  certain  to  occur  if 
the  affection  is  not  arrested  ;  and  when  ulceration  has  taken  place 
the  discharge  becomes  offensive  in  odor.  There  is  thickening  of 
the  mucous  membrane  from  inflammatory  swelling  and  infiltra- 
tion, producing  pain  and  a  sense  of  obstruction  to  nasal  respira- 
tion. Much  of  the  discharge  passes  anteriorly,  but  some  of  it  is 
apt  to  be  hawked  into  the  pharynx,  and  may  be  seen  upon  its 
posterior  wall  behind  the  palate,  in  thick  yellowish  or  greenish 
clumps.  These  irritate  the  mucous  membrane  of  the  pharj'iix, 
which  eventually  participates  in  the  infiammation  and  becomes 
ulcerated  ;  and  in  this  way  the  disease  may  be  propagated  to  the 
Eustachian  tubes  on  the  one  hand,  and  to  the  larynx  on  the 
other. 

In  the  tertiaiy  form  of  the  disease,  ulceration  of  the  mucous 

1  Feuerbach's  Account  of  Caspar  Hauser.     Boston.     1833. 


PARALYSIS    OF   THE    NOSTRILS.  203 

membrane  occurs,  and  graclnallj^  extends  into  the  cartilaginous 
and  osseous  structures,  producing  necrosis  and  permanent  de- 
formity of  the  nose  for  the  want  of  its  bony  support.  The 
peculiar  symptoms  attendant  upon  this  condition  have  been  nar- 
rated under  the  head  of  ozoena.  Sometimes  the  mucous  mem- 
brane seems  to  be  implicated  secondaril}',  after  the  disease  has 
progressed  in  the  bones.  The  external  soft  tissues  sometimes 
become  inyolved,  and  great  destruction  results,  producing  that 
condition  known  as  syphilitic  lupus.  In  a  case  of  this  kind  re- 
ported by  Dr.  Durkee,  of  Boston,  the  cryptogamic  parasite, 
sarcina  ventHculi,  was  found  in  abundance  in  the  discharge 
from  the  nostrils.^ 

The  secondary  manifestations  of  the  disease  are  managed  by 
local  ablutions  with  the  douche  or  syringe,  and,  if  necessary, 
the  internal  use  of  mercur}".  The  tertiary  form  of  the  disease 
requires  the  local  application  of  mercurials  and  detergents,  in 
addition  to  ablutions,  and  the  internal  administration  of  the 
iodide  of  potassium  and  the  bichloride  of  mercury ;  while 
dead  bone  must  be  removed  where  j)Ossible.  This  subject  has 
also  been  discussed  in  the  article  on  oza?na. 

PARALYSIS  OF  THE  NOSTRILS. 

A  single  case  of  parah'sis  localized  in  the  dilator  naris  muscle 
came  under  the  author's  observation  some  eio-hteen  months  a^o. 
A  gentleman,  occupying  a  prominent  position  in  a  public 
academy,  had  been  affected  for  some  years  with  a  difhculty  of 
breathing  through  his  nostrils,  which  produced  snoring  in  sleep, 
necessitated  liis  keeping  his  mouth  open,  which  brought  on 
23haryngitis  sicca,  and  rendered  him  otherwise  uncomfortable. 
Bidding  him  make  a  nasal  inspiration,  I  saw  that  the  nostril  closed 
externally  in  the  act.  Holding  the  nostril  away  from  the  septum 
by  a  pair  of  forceps,  I  found  that  breathing  went  on  tranquilly 
and  without  effort.  Careful  exploration  showing  that  there  was 
no  disease  in  the  tissues  of  the  nasal  passages,  the  opinion  was 
formed  that  there  was  paralysis  of  the  dilator  muscle  of  the 
nostril ;  and  local  applications  of  electricity  were  recommended. 

^  Am.  Jour.  Med.  ScL ,  Jan.  1854 ;  p.  96. 


294  AFFECTIOIS^S    OF   THE    NASAL    PASSAGES. 

As  the  patient  could  not  remain  in  the  city  at  that  time,  and 
wished  to  postpone  treatment  until  his  summer  vacation,  I  had 
two  silver  plates  made  the  size  of  the  nostrils,  separated  by  a  weak 
sprino- ;  the  plates  were  pressed  together  and  inserted  into  the 
nostril,  and  on  relieving  the  pressure  the  blades  expanded  and 
kept  the  nostril  dilated.  This  instrument  relieved  the  entire 
trouble.  It  was  not  visible  externalh^,  and  could  be  very 
readily  removed  for  jDurposes  of  cleansing.  As  the  patient  did 
not  return  at  the  period  of  his  vacation,  I  presume  he  felt  satis- 
fied with  the  relief  that  had  been  afforded. 

OCCLrSION    OF    THE   NOSTEILS. 

Mr.  Durham '  states  that  in  some  instances  the  nostrils  are 
more  or  less  completely  closed  by  membrane,^  in  others  by  firm 
fibrous  tissue,  or  by  simple  continuity  of  integument,  while  in 
other  cases,  one  ala  or  both  may  be  adherent  to  the  septum  or 
to  the  upper  lip.  In  the  treatment  of  this  class  of  cases  all 
that  is  usually  required  is  to  make  a  suitable  incision,  and  to 
keep  the  surfaces  apart,  by  pieces  of  lint  or  a  canula,  until  the 
parts  are  healed.  Constriction  and  occlusion  of  the  nostrils,  as 
the  result  of  accident  or  disease,  I  have  seen  following  fracture 
sustained  in  pugilistic  encounter,  and  also  as  a  result  of  contrac- 
tion following  ulceration.  The  mucous  membrane  was  thickened 
in  these  cases  from  interstitial  deposit,  and  where  this  is  the 
case  the  difficulty  can  often  be  overcome  by  pulling  off  patches 
of  mucous  membrane  so  as  to  leave  raw  wounds  of  some  size. 
As  the  edges  of  these  sores  cicatrize,  a  contraction  of  the  sides 
of  the  nostril  takes  place,  thereby  permanently  increasing  the 
caliber  of  the  tube.  The  operation  is  painful  and  bloody.  The 
repeated  employment  of  compressed  sponge,  or  perforated  rods 
of  laminaria,  increase  the  dilatation  and  maintain  it ;  but  their 
use  must  sometimes  be  persisted  in  for  months  together,  with 
occasional  resort  to  them  afterwards.  In  some  instances  it  is 
necessary  to  remove  more  or  less  of  the  middle  turbinated  bone 
in  order  to  secure  a  free  passage  for  the  air  through  the 
nostrils. 

^  Holmes'  System  of  Surgery,  Vol.  4. 

^Richerand  ;  Nosographie  Chirurgicale,  4th  Edit.,  tome  II.  p.  156. 


OCCLUSIOI^    OF   THE    POSTEEIOE    NAEES.  295 

Occlusion  of  the  nostril  may  occur  as  a  result  of  small-pox,  as 
in  the  case  of  Brown,  to  be  mentioned  in  connection  with  the 
subject  of  concretions  in  the  nasal  passages. 

Fracture  of  the  nasal  bones  and  fracture  of  the  nasal  carti- 
lage sometimes  produce  more  or  less  occlusion  of  tlie  nostrils, 
eitlier  as  an  immediate  result  of  the  accident,  or  as  an  effect  of 
the  infiannnation  following.  When  such  a  result  is  to  be  ap- 
prehended, the  nostrils  may  be  kept  sufficiently  pervious  for 
respiratory  purposes  by  the  use  of  metallic  tubes  inserted  into 
them. 

CONGENITAL    OCCLUSION    OF    THE    POSTERIOK   NAEES. 

Congenital  occlusion  of  the  posterior  nares  is  occasionally 
met  with.  A  single  instance  of  this  affection  has  come  under 
the  author's  personal  observation.  The  infant  had  great  diffi- 
cult}'' in  suckling  and  in  breathing,  and  was  subject  to  frequent 
suffocative  paroxysms.  An  opening  was  made  into  the  pharynx 
by  boring  through  the  structures  with  a  knife  and  a  steel  probe  ; 
and  this  was  kept  open,  and  enlarged  from  time  to  time  by  the 
passage  of  the  sound,  and  subsecpiently  of  small  bits  of  sponge 
securely  fastened  to  a  holder.  In  this  way  passages  were  madfe 
representing  the  lower  and  middle  meatuses.  The  operation 
was  always  attended  with  considerable  hemorrhage,  and  was  a 
frightful  one  in  appearance,  from  the  struggles  of  the  child,  the 
spattering  of  the  blood,  and  the  suffocative  spasms  that  it  pro- 
duced. As  soon  as  a  permanent  passage  was  secured,  the  child's 
nutrition  improved  at  once,  and  markedly. 

Dr.  Carl  Emmert  narrates '  a  case  upon  which  he  operated 
with  a  happy  result.  It  was  a  seven-year-old  boy,  who  from 
birth  had  been  unable  to  breathe  through  the  nose,  and  who 
was  nourished  when  an  infant  only-  with  great  difficulty.  He 
was  subject  to  attacks  of  suffocative  paroxysms  in  his  sleep.  The 
nose  was  well  formed,  but  the  choanse  were  entirely  closed.  'Not 
the  slightest  stream  of  air  was  perceptible  at  the  nostrils.  Mucus 
was  continually  running  from  them,  and  on  weeping,  the  dis- 
charge was  accompanied  by  a  stream  of  tears.     The  closure  of 

^  (Lehrbuch  der  Chirurgie,  Stuttgart,  1853,  Bd.  II.  p.  535.)  Luschka  ;  Der 
ScMundkopf  der  Menschen,  1868,  p.  27. 


296  AiTECTiojsrs  of  the  nasal  passages. 

the  choanse  was  due  in  this  case,  as  shown  by  a  preliminary  ex- 
amination with  the  sound,  and  as  confirmed  during  the  opera- 
tion, to  the  presence  of  a  bony  wall  or  partition,  covered  on  both 
sides  with  mucous  membrane  ;  but  it  was  impossible  to  ascertain 
in  what  manner  or  from  which  bones  this  complete  anterior 
wall  of  the  naso-pharyngeal  space  took  its  origin. 

Luschka,  in  continuation  of  the  subject,  narrates  the  following 
case  which  occurred  under  his  own  observation :  It  was  a  female 
infant  who  died  shortly  after  birth.  The  bony  fomidation  was 
formed,  on  both  sides,  from  the  palate  bone.  The  free  sloping 
border  of  the  normally  sized  horizontal  portion  was  continued  in 
the  form  of  a  thin  compact  lamella,  which  inclined  somewhat 
outwards  and  backwards,  and  rose  up  as  high  as  the  inferior 
face  of  the  sphenoid  bone,  with  which  it  was  connected  by  a 
dentated  border.  Tlie  plate  of  bone  rested  with  sharp  border 
upon  the  median  side  of  the  internal  laminae  of  the  wings 
of  the  sphenoid.  In  the  middle  line,  where,  in  the  normal 
condition,  the  nasal  spine  arises,  the  lamella  joined  with  that  of 
the  opposite  side  ;  while  both,  in  their  further  course  upwards, 
were  separated  by  a  very  narrow  fissure,  in  which  the  posterior 
border  of  the  rudimentary  vomer  had  its  attachment. 

INFLAJSIMATION    OF    THE    SEPTUISI   NAEIUM. 

Inflammation  of  the  septum  narium  sometimes  occurs  as  the 
result  of  injury  or  external  ^dolence.  This  may  lead  to 
the  formation  of  an  abscess.  Inflammation  and  abscess  also 
occur  independently  of  local  injury.  There  is  pain,  heat,  dry- 
ness, and  swelling  of  the  parts,  sometimes  in  sufiicient  extent 
to  occlude  the  nostrils  completely.  The  pain  often  extends  to 
the  frontal  sinuses.  The  abscess  may  form  on  either  side  of 
the  septum,  or  on  both  sides.  The  diagnosis  is  easy.  The 
appearance  of  a  tumor,  the  sense  of  fluctuation,  and  the  history 
of  the  case,  with  more  or  less  manifestation  of  fever,  indicate 
the  nature  of  the  affection. 

The  local  treatment  consists  in  prompt  incision  of  the  abscess 
and  evacuation  of  its  contents.  If  the  parts  do  not  retui-n 
promptly  to  their  natural  condition,  the  local  use  of  the  mineral 
astringents  may  be  called  for. 


SUBMUCOUS    INFILTEATION    OF    NASAL    SEPTUxM.       297 

Chronic  inflammation  of  the  nose,  especially  in  syphilitic  and 
scrofulous  cases,  not  unfrequently  terminates  in  ulcerative 
destruction  of  more  or  less  of  the  cartilaginous  septum.  There 
may  be  several  perforations,  or  one  large  orifice ;  more  fi-e- 
quently,  perhaps,  the  latter.  Yery  often  the  result  of  the 
examination  by  the  surgeon  will  be  the  first  intimation  to  the 
patient  of  the  existence  of  a  perforation.  It  is  met  with  inde- 
pendently of  any  history  of  local  disease  within  the  patient's 
merhory.  Some  authors  believe  it  to  be  congenital.  The  pro- 
babiKty,  however,  is,  in  at  least  a  fair  proportion  of  instances, 
that  the  perforation  has  resulted  during  the  course  of  a  syphili- 
tic coryza  in  early  infancy. 

If  the  edges  of  the  perforation  show  any  disposition  to  ulcer- 
ation they  should  be  washed  with  a  solution  of  nitrate  of  silver 
or  some  substitute  ;  otherwise  careful  washing  with  warm  water 
or  soap-suds,  conveyed  on  the  end  of  a  soft  rag,  will  remove  the 
inspissated  mucus  which  sometimes  adlieres  to  the  edges,  and 
thus  keep  the  parts  clean  and  comfortable. 

Operations  have  been  j)erformed  for  the  closure  of  the  per- 
foration by  plastic  transplantation. 

SUBMUCOUS    INFILTEATION    AT    THE    SIDES    OF   THE    YOISIEE. 

Since  my  attention  has  been  directed  to  rhinoscopy,  I  have 
yery  frequently  met  with  a  peculiar  condition  of  parts  in  nasal 
troubles  which,  as  far  as  I  am  aware  of,  has  hot  yet  been  speci- 
ally described.  It  consists  in  a  puffy  condition  of  the  mucous 
membrane  on  the  sides  of  the  posterior  nasal  seiDtum.  From 
personal  experience,  and  as  the  result  of  conversations  with  Dr. 
Elsberg,  of  New  York,  and  others,  I  am  inclined  to  believe  that 
it  is  a  very  common  affection. 

The  sjTnptoms  are  those  of  an  obstruction  at  the  posterior 
nares,  and  they  are  often  referred  to  polyps.  On  examination 
with  the  rhinoscope  we  observe  at  each  side  of  the  septum,  and 
confined  to  the  posterior  portion,  a  tumid  mass,  of  a  whitish 
color,  markedly  distinct  from  the  red  color  of  the  adjacent- 
mucous  membrane.  The  mass  almost  always,  as  I  have  seen  it, 
occupies  the  lower  portion  of  the  septum,  extending  ujd wards  to 
a  greater  or  less  extent,  and  sometimes  occupying  the  entire 


298      AFFECTIOA^S  OF  THE  NASAL  PASSAGES. 

length  of  the  septum,  I  have  never  seen  it  at  the  upper  part, 
with  a  line  of  demarcation  below.  The  affection  is  usually 
symmetrical,  but  often  exists  to  a  greater  extent  upon  one  side 
than  the  other.  The  masses  are  roundish,  with  very  convex 
outlines,  and  sometimes  extend  half  way  across  the  choanse,  and 
occasionally  very  close  to  the  outer  margins  of  the  nares,  if  not 
in  contact  with  them.  The  appearance  of  the  mass  is  sugges- 
tiA-e  of  polyjD,  but  it  is  by  no  means  of  this  character.  It 
appears  to  be  an  (Edematous  protrusion  of  the  mucous  mem- 
brane from  an  accumulation  beneath  it  of  serum  or  serous 
mucus.  The  tumor  usually  yields  readily  to  the  pressure  of  the 
probe  or  other  instrument,  carried  up  behind  the  palate,  or.  in- 
troduced through  the  nostril,  being  soft  and  elastic  to  the  touch. 

This  condition  exists  sometimes,  to  a  very  limited  extent,  in 
cases  of  ordinary  chronic  coryza,  but  the  oedematous  protrusion 
is  slight,  and  apt  to  be  constricted  at  one  or  two  points  of  its 
extent;  a  similar  moderated  degree  of  the  affection  occasion- 
ally attends  cases  of  glandular  enlargement  at  the  vault  of  tJie 
pharynx. 

The  treatment  of  this  affection  in  my  hands  has  consisted  in 
tearing  away  portions  of  the  protrusions  by  forceps  carried  up 
behind  the  palate,  or  introduced  through  the  nostril,  as  the 
case  may  be ;  or  puncturing  them  with  the  larj^igeal  lancet, 
the  operation  being  performed  under  guidance  of  the  rhino- 
scope.  There  is  not  usually  a  great  deal  of  hemorrhage.  After 
the  operation  the  parts  are  cauterized. 

The  manipulation  is  an  exceedingly  difficult  one  in  many 
instances,  severely  taxing  the  patience  and  ingenuity  of  the 
operator,  as  well  as  the  endurance  and  amiability  of  the  patient. 
Mere  puncture  with  the  concealed  lancet  has  not  afforded  good 
results  in  my  hands,  though  it  will  unload  the  part  for  the 
time.  The  cicatrization  of  the  edges  of  the  wound  made  by 
tearing  away  the  mucous  membrane  enlarges  the  passage  for 
air,  and  is  in  this  way  beneficial. 

The  affection  is  an  obstinate  one,  and  apt  to  recur  again  and 
again. 

I  look  upon  the  affection  as  similar,  in  many  respects,  to  the 
protrusi(Dns  of  the  mucous  membrane  met  with  in  the  anterior 


SUBMUCOUS    liN^FILTKATION    OF    NASAL    SEPTUM.       299 


nares  and  simulating  polyp ;  only  in  the  latter  cases  the  tumors 
are  red,  and  in  the  former  cases  they  are  white  or  whitish. 

The  use  of  the  galvano-cautery  would  form  an  appropriate 
means  of  destroying  these  protrusions,  from  the  promptness 
with  which  it  acts,  as  it  is  hard  for  patients  to  bear  contact 
with  these  pai-ts  for  more  than  a  second  or  two,  but  fi-om  want 
of  a  skilled  assistant,  and  the  amount  of  trouble  required  in  its 
use  in  cases  of  this  kind,  I  have  not  resorted  to  it,  though  fi'e- 
quently  tempted  to  do  so. 

Figs.  56  and  57  from  two  of  my  cases  will  serve  to  illustrate 
the  nature  of  this  affection.     The  tumid  swellings  are  easily 

Fig.  56.  Pig.  57. 


Ehinoscopic  Image  of  Oidema  of 
Kasal  Septum. 


Ehlnoscopio  Image  of  CEdema  of 
Kasal  Septum. 


Fig.  68. 


recognized   each  side  of  the  septum,  where  they  cut  off  the 
views  of  the  turbinated  bones. 

Fig.  58  represents  a  marked  case  of  this  affection  in  the 
person  of  a  medical  gentleman  under  my  care  at  the  moment 
of  writing.  The  view  represents  a 
prominent  view  of  the  left  side  of 
the  pharyngo-nasal  region,  represent- 
ing the  phar}Tigeal  end  of  the  Eus- 
tachian tube  of  that  side  and  its 
orifice,  and  a  deep  indentation  or 
groove  marking  the  boundary  line 
between  the  vault  of  the  pharynx 
and  the  nasal  portions.  This  'space 
and  the  fossa  of  Rosenmuller  below 
it  was  bridged  by  numerous  bands 
of  adhesions.  A  portion  of  the 
edematous  membrane  of  the  left  side  was   pulled   off  with 


Siibmucous  Infiltration  of  Posterior 
Nasal  Septum,  supposed  to  be  due 
to  Mycelium. 


300  AFFECTIOISrS    OF    THE    NASAL    PASSAGES. 

angular  forcej)s  passed  behind  the  soft  palate,  and  the  mass  ot 
jellj-like  consistence  carried  by  the  gentleman  to  Dr.  J.  Gibbons 
Hunt,  a  distinguished  microscopist  of  Philadelphia,  who  discov- 
ered in  it  abundant  evidence  of  the  vegetable  fungus  mycelium, 
and  advised  the  local  use  of  carbolic  acid  for  its  destruction. 
The  application  has  been  made  two  or  three  times,  but  so  far 
without  effect. 


TUMOES    OF    THE    SEPTUM. 

Tumors  of  various  kinds  occasionally  appear  in  the  septum. 
These  may  be  mere  ecchymoses,  the  result  of  blows,  which 
appear  as  tumid  swellings,  sometimes  on  one  side,  sometimes 
on  both.  Their  prompt  appearance  and  the  history  of  violence 
will  serve  to  intimate  their  true  nature.  They  usually  subside 
spontaneously  by  absorption  of  the  effused  blood.  If  this  does 
not  take  place,  their  contents  should  be  evacuated  by  incision, 
otherwise  they  may  provoke  inflammation  and  abscess. 

Colloid  tumors  are  said  to  occur  occasionally  in  this  situation. 
The  treatment  would  consist  in  evacuation  of  the  sac  by  ex- 
cision, and  local  medication  of  its  remains  so  as  to  excite 
adhesive  inflammation. 

Cartilaginous  tumors  are  said  to  grow  occasionally  on  the 
septum,  and  usually  require  external  division  of  the  nose  for 
their  removal.  The  cartilaginous  hy]3ertrophy  of  the  sej)tum 
sometimes  encountered,  is  spoken  of  in  connection  with  the 
subject  of  deviations  of  the  septum. 

Fractures  of  the  nasal  septum  occasionally  occur,  and,  when 
comminuted,  may  obstruct  the  nostril  to  a  considerable  degree. 
Prof.  Gross  ^  mentions  a  case  brought  to  hiui  four  months  after 
the  septum  had  been  broken  into  several  pieces,  in  which  there 
was  encroachment  upon  the  left  nostril  to  such  an  extent,  as  to 
cause  almost  complete  obstruction  to  respiration  on  that  side. 
In  order  to  afl^ord  relief  he  was  compelled  to  cut  away  the 
whole  of  the  offending  part. 

'  System  of  Surgery. 


rOEEIGX   BODIES    IIST   THE    NOSTEILS.  301 

DEVL1TI0X3    OF    SEPTUISI    FROM   l^nDDLE   LINE. 

A  snb-periosteal  resection  of  the  nasal  septum  for  the  remedy 
of  deviation  has  l)een  resorted  to  by  M.  Chassaignac.'  A  cur- 
vilinear incision  is  made  in  the  ant ero- posterior  direction  low 
down  into  the  mucous  membrane,  and  this  flap  is  separated  from 
the  cartilage  by  means  of  a  spatula,  and  then  turned  over.  Sev- 
eral slices  are  then  cut  from  the  cartilage  until  a  point  has  been 
reached  which  admits  of  its  being  readily  pushed  over  to  the 
middle  line.  The  flap  of  mucous  membrane  is  now  rejjlaced, 
and  the  parts  are  retained  in  their  new  position  by  a  bit  of 
sponge  inserted  into  the  nostril. 

The  unpleasant  symptoms  of  this  affection  are  sometimes 
relieved  by  cutting  out  a  piece  of  the  septum,  and  thus  estab- 
lishing a  communication  between  the  two  passages. 

Other  surgeons  have  divided  the  nose  in  the  middle  line  and 
resected  the  septum. 

A  few  years  ago  I  saw  Prof.  Pancoast  relieve  a  case  of  this 
kind,  attended  by  deformity  of  the  organ  to  one  side,  in  which 
the  deviation  had  been  acquired  by  blowing  the  nose  by  the  aid 
of  the  finger  and  thumb.  The  nostrils  were  tamponed  ante- 
riorly and  posteriorly ;  and  the  cartilaginous  portion  of  the 
septum  separated  fi'oni  the  bony  portion  by  subcutaneous 
division  with  a  tenotome.  The  organ  was  then  forcibly  pulled 
to  the  oj^posite  side,  and  maintained  in  position  by  adhesive 
strips. 

Much  can  be  done  in  some  instances  by  inserting  metallic 
tubes  in  the  nostrils  and  exercising  dilatation  and  gentle  com- 
pression in  this  way.  The  use  of  the  compressed  sponge,  or  of 
the  tubes  of  laminaria,  as  mentioned  in  connection  with  the 
subject  of  tliickening  of  the  nasal  mucous  membrane,  will  often 
succeed  eventually  in  overcoming  a  deviation  of  the  septum, 
without  any  necessity  for  a  resort  to  the  knife. 

FOBEIGN   BODEES    IN   THE    NOSTEILS. 

Children  very  often  insert  foreign  bodies,  such  as  peas,  beans, 
small  stones,  etc.,  into  the  nasal  passages,  which,  if  discovered, 

1  Oaz.  Hebd.,  June  11,  1869,  p.  380. 


302      AFFECTIONS  OF  THE  NASAL  PASSAGES. 

or  acknowledged  by  tlie  child,  are  very  readily  removed. 
Sometimes  they  are  forgotten  and  remain  impacted  for  years, 
keeping  up  vs^ell  into  adult  life  an  irritating  and  often  offensive 
discharge,  which  is  supposed  to  be  due  to  nasal  catarrh  of 
scrofulous  oi-igin,  or  to  ozsena.  The  foreign  body  becomes 
incrusted  with  calcareous  matter,  and  sometimes  forms  the 
nucleus  for  a  veritable  calculus  ;  and  may  eventually  produce 
necrosis  of  one  or  more  of  the  turbinated  bones,  necessitating 
their  remcjval,  at  which  time  the  cause  of  the  life-long  discharge 
is  discovered  to  have  been  the  presence  of  an  impacted  foreign 
body,  unsuspected  or  long  forgotten. 

Strict  inquiry  as  to  the  presence  of  a  foreign  body  should 
always  be  instituted  in  every  case  of  offensive  discharge  from 
the  nostrils  ;  and  the  word  of  the  patient  or  friends  should  not 
be  depended  upon.  It  is  the  duty  of  the  medical  attendant  to 
wash  the  parts  thoroughly,  and  then  examine  them  carefully  by 
a  good  light,  both  by  inspection  of  the  nostrils  anteriorly,  and, 
where  practicable,  posteriorly,  in  the  rhinoscopic  mirror. 

A  foreign  body  is  rarely  introduced  into  the  nostrils  of  the 
adult  except  by  accident,  the  exceptions  being  confined  to 
patients  with  hysteria,  or  insanity. 

Usually,  the  presence  of  a  foreign  body  in  the  nostril  pro- 
duces inflammatory  action,  dependent  a  good  deal  upon  the 
shape  of  the  body  and  the  character  of  its  edges.  If  it  be 
sharjD,  spiculated,  or  irregular,  the  irritation  will  be  much  more 
than  when  it  is  smooth  in  contour.  This  inflammation  will  re- 
sult in  the  production  of  a  catarrh  which  will  be  likely  to  take 
on  the  appearance  of  a  chronic  coryza,  with  the  copious  secre- 
tion of  pus  ;  while,  if  the  foreign  body  be  of  a  large  size  com- 
paratively, or  be  of  such  a  character  as  to  become  swollen  at 
the  place  of  impaction,  the  nose  will  become  distended  out  of  its 
normal  shape,  and  the  pain  and  other  local  symptoms  will 
increase  in  severity.  Sometimes  ulceration  will  be  set  up  in 
the  parts  against  which  the  foreign  body  is  lodged,  and  this 
will  complicate  the  condition  of  things. 

AVhen  foreign  bodies  remain  a  long  time  in  the  nasal  cavities, 
they  are  apt  to  become  incrusted  with  the  saline  portions  of  the 
serum  which  is  secreted  in  consequence  of  the  irritation  they 


FOEEIGJSr    BODIES    IN   THE    ISTOSTRILS.  303 

produce,  and  in  this  way  form  the  rhinohths  or  nasal  calculi 
sometimes  found  in  this  region.  These  may  be  very  small,  or 
increase  by  accretion  to  the  size  of  a  hazel-nut  or  larger. 
Sometimes  they  are  discharged  spontaneously,  but  usually  have 
to  be  extracted  by  surgical  procedure,  generally  with  the  forceps. 
Their  presence  is  usually  detected  by  the  probe,  though  some- 
times they  are  exposed  to  inspection  on  distending  the  nostril. 

Occasionally  the  foreign  body  is  an  insect  which  has  crawled 
into  the  nostrils  from  without ;  a  leech ;  or  a  human  parasitic 
worm  which  has  crawled  into  the  posterior  nares  from  the 
stomach.  In  cases  of  the  latter  kind,  the  parasites,  usually 
ascarides,  may  crawl  into  the  frontal  sinus,  producing  intense 
headache  and  leading  to  delirium,  which  may  end  fatally.  The 
older  physicians  used  to  attribute  bad  cases  of  oztena  attended 
with  severe  pain  in  the  frontal  region  to  the  presence  of  in- 
sects or  their  larvge  in  this  situation. 

The  treatment  for  a  foreign  body  in  the  nostril  should  be 
directed  to  its  removal  at  the  earliest  moment.  In  some  instances 
it  can  be  dislodged  by  exciting  the  act  of  sneezing  by  the  use  of 
snuff,  or  by  tickling  the  mucous  membrane  with  a  feather.  The 
injection  of  a  strong  stream  of  water  through  the  nostril  from 
behind  forwards  by  means  of  the  posterior  nasal  syringe,  or  the 
douche  of  Thudichum  passed  from  the  sound  nostril,  will  some- 
times succeed  in  driving  the  foreign  body  out  the  road  it  entered. 
If  the  nasal  douche  be  employed  for  this  pui-pose,  the  reservoir 
should  be  placed  very  high,  so  as  to  lend  as  much  force  as  possible 
to  the  current.  Curved  bougies  or  catheters  may  be  passed 
from  behind  forwards,  in  the  hope  of  getting  in  the  rear  of  the 
obstacle  and  pushing  it  towards  the  exterior.  Where  the  foreign 
body  is  impacted,  and  there  is  danger  of  pushing  it  farther  on 
by  the  use  of  instruments  inserted  into  the  nostrils,  attempts 
should  be  made  in  the  manner  indicated  to  push  it  out  forwards 
from  behind.  This  is  a  much  better  plan  than  the  opposite 
one  sometimes  employed,  an  endeavor  to  push  the  body  on  into 
the  pharynx  and  then  extract  it  through  the  mouth. 

Unless  the  foreign  body  be  favorably  situated  and  of  suitable 
shape,  the  forceps  should  not  be  used  to  extract  it,  on  account 
of  the  danger  of  impacting  it  more  firmly.     This  is  particularly 


304 


AFFECTIONS    OF    THE    ]S"ASAL    PASSAGES. 


Fig.  59. 


tlie  case  with  bodies  of  rounded  or. smooth  contonr,  such  as 
beans,  peas,  beads,  and  the  like.  A  much  better  plan  is  to  at- 
tempt to  pass  a  slender  hook  behind  the  body,  and  draw  it  for- 
v^ard;  for  which  purpose  the  little  rectangular  hook,  or  the 
screw  devised  by  Prof.  Gross  for  the  removal 
of  foreign  bodies,  and  which  is  attached  to  the 
ear-scoop  furnished  in  the  pocket-case  kno-wn 
as  "Gross's  pocket-case,"  is  a  most  admirable 
instrument;  for  there  is  almost  always  room 
enough  to  pass  so  slender  a  body  between  the 
obstacle  and  the  wall  of  the  nostril. 

In  cases  of  the  presence  of  parasites  in  the 
nasal  cavities,  it  has  been  proposed  to  kill 
them  by  the  injection  of  vapors  of  alcohol, 
turpentine,  etc.;  or  by  the  injection  of  vermi- 
fuges, such  as  are  employed  to  kill  worms  in 
the  intestines.  These  parasites  have  been 
known  to  penetrate  into  the  frontal  sinuses ; 
and  in  one  instance,  alluded  to  by  Trelat,'  to 
have  necessitated  trepanning  the  sinus,  in 
order  to  be  able  to  extract  them. 

Dr.  C  Coquerel  reported^  five  cases  in 
which  the  larvse  of  diptera  in  the  nasal 
passages  and  frontal  sinuses  produced  vio- 
lent symptoms,  followed  by  death  in  three  of  the  cases.  In 
most  of  the  cases,  several  hundred  larvse  were  evacuated  by 
ulceration  and  necrosis  of  parts  investing  the  cavities.  These 
cases  occurred  at  the  convict  hospital  at  Cayenne ;  and  it  is  sup- 
posed that  the  larvae  were  the  issue  of  eggs  dej^osited  in  the 
nasal  fossae  by  a  peculiar  fly,  and  were  not  parasites.  In  tlie 
original  article  Dr.  Coquerel  quotes  several  analogous  cases 
from  authors  who  had  observed  similar  occurrences  in  Europe. 
A  somewhat  similar  case  was  communicated  many  years  ago 
to  the  Philomathic  Society,  by  M.  Jules  Cloquet.^ 


Gri'oss's  instruments  for 
removal  of  foreign 
bodies  from  the  nose. 


1  Gazette  Hebd.,  1867,  No.  51,  p.  814. 

2  {Arch.   Gen.  de  Med.,  May,  1858;   Brit,  and  For.  Med.-Chir.  Rev.,  Oct., 
1858);  Am.  Jour.  Med.  Sci.,  Jan.,  1859,  p.  255. 

^  Am.  Jour.  Med.  Sci.,  May,  1838,  p.  228. 


CALCAEEOUS    ACCEETIONS    IJ^    THE    NOSTRILS.         305 

In  cases  of  foreign  bodies  of  long  standing,  where  the  usual 
means  of  extraction  have  proved  unsuccessful,  or  are  unavail- 
able, it  has  become  necessary  to  seek  the  foreign  body  through 
an  external  incision ;  to  which  end  Yidal  has  recommended 
division  of  the  wing  of  the  nose,  and  Dieffenbach  its  division 
in  the  middle  line. 

In  cases  of  foreign  bodies  impacted  in  the  frontal  sinuses,  it 
has  been  proposed  to  divide  the  nose  at  its  root,  and  turn  it  over 
upon  the  face  ;  an  operation  which  has  also  been  recommended 
for  obtaining  access  to  tumors  in  the  same  situation. 

CALCAHEOUS   ACCEETIONS   IN   THE   NASAL   EOSS^. 

Calculi,  as  already  mentioned,  are  occasionally  met  with  in 
the  nasal  f ossse ;  their  origin  being  usually  due  to  some  foreign 
body  of  suitable  size  and  consistence,  which  has  been  forced  up 
the  nose  in  childhood,  and  eventually  been  converted  into 
a  nucleus  for  the  deposit  of  calcareous  matters.  In  other  cases 
they  have  been  found  to  be  due  to  a  deposit  of  the  inspissated 
mucus,  or  sanguinolent  secretions  from  the  inflamed  mucous 
membrane.  Such  accretions  are  known  as  rhinoliths.  They 
are  generally  movable,  and  readily  broken  into  fragments,  being 
composed,  according  to  Demarqnay,'  of  phosjohates  of  lime 
and  magnesia,  chloride  of  sodium,  and  carbonate  of  lime,  mag- 
nesia, and  soda. 

Sometimes  they  are  found  without  any  apparent  cause  what- 
ever ;  and  their  appearance  is  attributed  to  the  gouty  diathesis, 
in  the  same  way  as  is  the  appearance  of  gouty  concretions  some- 
times observed  in  the  membrana  tyrapani. 

These  rhinoliths  vary  in  size,  from  that  of  a  small  bead  to 
that  of  a  hazel-nut ;  and  they  may  obstruct  the  nasal  passage 
completely,  pressing  the  septum  before  them  so  as  to  encroach 
upon  the  caliber  of  the  other  nostril.  They  give  rise  to  the 
ordinary  symptoms  of  obstruction  and  irritation,  with  frontal 
or  nasal  pain,  constant  or  intermittent ;  and  may  induce  severe 
inflammation,  with  a  copious  muco-purulent  discharge.     Some- 

^  Memoires  sur  les  calculs  nasaiix.     Archives  Oenerales  de  Mtdecine^  4  Ser.. 
VoL  viii.,  p.  174,  June,  1845, 
20 


306  AFFECTIOlSrS    OF    THE    IS^ASAL    PASSAGES. 

times  small  concretions  are  discharged  into  the  handkerchief, 
at  once  indicating  the  nature  of  the  affection.  Examination  by 
the  sjDeculum  anteriorly  and  by  the  rhinoscope  posteriorly 
will  sometimes  lead  to  their  detection.  In  other  instances  they 
are  recognized  by  the  touch  on  careful  exploration  of  the  walls 
of  the  cavity  and  the  surface  of  the  turbinated  bones  with  the 
probe.  Care  must  be  taken  against  mistaking  them  for  ex- 
posed bone.  Before  commencing  the  exploration  it  will  be 
advisable  to  wash  away  the  secretions  of  the  parts  as  thoroughly 
as  may  be,  by  means  of  the  syringe  applied  posteriorly  as  well 
as  anteriorly.  Perhaps,  with  a  view  to  detachment,  it  will  be 
better  to  begin  the  cleansing  process  with  the  posterior  nasal 
syringe. 

The  treatment  consists  in  removal  of  the  concretions,  an 
operation  which  must  often  present  some  difficulty.  "Where 
they  are  quite  accessible,  delicate  j)olyp  forceps  can  be  em- 
ployed. Mr.  Durham,  in  Holmes'  Surgery,  suggests  delicate 
forceps  with  separate  blades,  similar  to  midmfery  forceps. 
Where  the  calculus  is  large  and  apt  to  injure  the  soft  parts  in 
its  removal  it  might  in  some  instances  be  crushed,  in  order  to 
facilitate  extraction ;  and  the  debris  could  be  washed  out  from 
behind  by  a  stream  of  water  from  the  posterior  nasal  syiinge, 
or  from  a  nasal  douche  entering  by  the  opposite  nostril.  In 
some  instances  a  knife  might  be  passed  under  the  edge  of  the 
calculus  a  short  distance  into  the  soft  parts,  and  the  calculus  be 
then  pried  out  in  part  by  a  blunt  instrument. 

Occasionally  the  concretion  may  be  pent  up,  in  consequence 
of  adhesion  of  the  nostrils ;  as  occurred  in  a  case  reported  by 
Wm.  H.  Bro^^m,'  in  a  patient  whose  nostrils  were  closed  by 
cicatricial  tissue,  the  result  of  small-pox  in  childliood.  An  in- 
cision throuofh  the  occludino-  membrane  enabled  him  without 
difficulty  to  extract  the  stone,  which  weighed  three  drachms 
and  thirty-three  grains. 

Sometimes  the  presence  of  these  concretions  keeps  up  local 
suffering  for  years.  A  very  curious  case  of  periodical  hemi- 
crania,  terminating  by  the  evacuation  of  a  nasal  calculus,  has 

»  Edin.  Med.  Jour.    Yol.  v. ,  p.  50. 


TUMOES    IN    THE    IN'ASAL    PASSAGES.  307 

been  recorded  by  Dr.  Axmann.'  A  female,  aged  lifteen,  com- 
plained of  pain  in  the  region  of  the  left  frontal  sinus,  extend- 
ing to  the  same  side  of  the  head.  It  returned  daily  at  10  a.m., 
and  lasted  until  5  p.m.  Sometimes  the  pain  was  excessive, 
affecting  the  left  side  of  the  face,  and  inducing  tumefaction 
around  the  eye ;  and  during  the  paroxysms  there  were  nausea 
and  vomiting.  The  left  nostril  was  dry.  She  married  at  twen- 
ty-one and  bore  children  during  fifteen  years,  and  with  slight 
exception  was  comparatively  well.  Three  years  after  her  last 
delivery  the  headache  returned  with  violence ;  and  she  was 
under  treatment  for  two  years,  when,  under  the  influence  of  a 
pinch  of  snuff,  a  calculus,  the  size  of  a  bean,  escaped  from  the 
left  nostril.  During  the  following  year  she  passed  several  cal- 
culi under  the  influence  of  sternutatories,  and  the  effect  was 
followed  by  a  discharge  of  fetid  pus  ;  since  which  time  the  wo- 
man had  remained  perfectly  well. 

TUMOKS    m   THE    NASAL   PASSAGES. 

Tumors  are  frecpiently  met  with  in  the  nasal  passages  and 
their  communicating  ca^dties.  They  have  their  origin,  usually, 
in  the  mucous  membrane,  but  are  occasionally  connected  with 
the  periosteum  or  perichondrium. 

The  most  frequent  variety  of  tumor  encountered  in  this  situ- 
ation is  that  of  the  polyp,  which  presents  itself,  in  the  form  of  a 
roundish  or  elongated  body,  usually  pedunculated,  but  some- 
times attached  by  a  broad  base,  and  varying  in  size  from  that 
of  a  small  bean  to  a  size  large  enough  to  distend  the  nose 
out  of  shape,  and  obstruct  the  respiration  through  the  organ 
completely.  There  are  several  varieties  of  polyp,  the  most  fre- 
quent of  which  is  the  mucous  or  gelatinous  polyp,  which  springs 
from  the  mucous  membrane,  originating  in  an  enlargement  of 
the  acinous  glands,  with  which  the  nasal  mucous  membrane  is 
so  richly  provided.  As  the  gland  enlarges,  the  mucous  mem- 
brane covering  it  becomes  hypertrophied  and  elongated,  which, 
with  its  contents,  constitutes   the  polyp.      It  is  of  a  whitish 

^  {Heidelberg  Klin.  Annalen ;  ArcJi.  Gen.^  May,  1829) ;  Am.  Jour.  Med.  Sd. 
Vol.  v.,  p.  304. 


308 


AFFECTIOlSrS    OF   THE    NASAL    PASSAGES. 


Fig.  60. 


color,  and  of   soft  consistence;    its   appearance  is  not  unlike 
that  of  an  oyster,  to  whicli  it  has  been  aptly  compared.     It  is 

nsnally  pedunculated,  of  an  ir- 
regular pyriform  shape,  with 
smooth  surface,  and  usually  hangs 
downwards  into  the  nostril,  or 
backwards  out  of  the  posterior 
nares ;  the  former  much  more 
frequently.  Sometimes  it  is  im- 
pacted in  the  free  space  of  the 
nasal  cavity.  The  point  of  origin 
is  usually  the  superior  turbinated 
bone,  though  it  may  arise  from 
the  other  turbinated  bones.  It  is 
much  more  frequently  multiple ; 
masses  come  into  view  after  the 


Gelatinoid  nasal  poljnp. 

sometimes    solitary,    but 
and,  occasionally,  immense 


removal  of  a  large  polyp  —  masses  which,  when  removed, 
seem  to  occupy  much  more  space  than  that  of  the  cavi- 
ties in  which  they  grew.  On  account  of  their  soft  consistence, 
these  smaller  polyps  become  closely  packed  in  the  recesses  of 
the  nasal  cavities,  never  having  had  room  to  expand  until  the 
removal  of  other  masses  which  had  been  compressing  them. 

This  form  of  polyp  swells  in  damp  weather,  on  account  of  the 
hygrometric  nature  of  its  contents. 

These  polyps  are  usually  produced  as  a  result  of  chronic 
coryza ;  "  from  the  simple  hyperplasia  of  which,"  says  Virchow, 
"  polypi  take  their  origin ;  which,  at  a  later  period,  may  become 
the  seat  of  veritable  cancer." 

A  much  less  frequent  variety  of  the  polyp  is  the  fibroid  or 
fibrous  polyp,  a  growth  of  much  firmer  consistence  ;  taking  its 
origin  not  from  the  mucous  membrane,  but  from  the  coimective 
tissue  beneath  it,  or  even  from  the  perichondrium  or  periosteum, 
as  the  case  may  be.  It  is  usually  single,  and  attached  by  a 
broad  base,  though  often  met  with  a  small  j^edicle.  It  acquires 
a  larger  bulk  than  the  gelatinoid  polyp,  is  of  much  firmer  con- 
sistence, and  red  in  color,  like  the  color  of  the  surrounding  mu- 
cous mem1)rane.  When  not  removed  it  is  liable  to  grow  in 
every  direction,  protruding  backwards  into  the  pharynx,  and 


TUMORS    IN   THE    I^ASAL    PASSAGES.  309 

insinuating  itself  by  prolongations  into  the  sinnses  eommnnieat- 
ing  with,  the  nose,  so  as  to  produce  that  species  of  deformity 
which  has  been  termed  "  fi-og-f ace."  Sometimes  it  forms  con- 
nections with  the  base  of  the  skull,  in  the  same  manner  as  the 
naso-pharyngeal  polyp,  and  on  this  account  subjects  the  patient 
to  consequences  of  the  most  serious  nature,  fi'om  the  effects  of 
an  operation  for  its  removal. 

A  form  of  polyp  denominated  granular  is  also  occasionally 
found  in  the  nasal  cavity.  This  glandular  polyp,  also,  occa- 
sionally takes  similar  connections,  and  renders  its  possessor 
liable  to  serious  accident  as  a  result  of  operation. 

A  remarkable  case  of  this  kind  occurred  in  the  service  of  M. 
Demarquay,^  in  which  a  physician  seventy-four  years  old  had 
suffered,  for  four  years  previously,  with  an  abscess  of  the  frontal 
sinus,  which  was  cured  by  trepanning  the  anterior  wall  of  the 
sinus.  In  September,  1868,  Demarquay  extirpated  a  nasal  polyp, 
the  operation  being  followed  in  three  days  by  erysipelas  of  the 
face,  which  pursued  its  usual  course,  and  in  a  few  days  the 
patient  returned  home  well.  In  January,  1869,  he  returned,  on 
account  of  an  affection  of  the  right  nostril ;  and  Demarquay 
removed  a  polyp  the  size  of  a  walnut,  and  grayish- white  in 
color.  On  the  seventh  day  erysipelas  again  set  in,  but 
passed  off  without  any  unpleasant  result.  On  March  23  the 
patient  returned  with  a  fresh  polyp,  which,-  on  examination, 
was  found  to  fill  up  the  choance.  April  2,  Demarquay  extracted 
it  with  polypus-forceps,  and  cauterized  the  nasal  mucous  mem- 
brane with  the  solid  nitrate  of  silver.  In  the  evening  the 
patient  complained  of  severe  pain  in  the  right  side  of  the  head, 
for  the  relief  of  which  a  hypodermic  injection  of  .01  grannne  of 
morphia  was  used,  which  was  followed  by  marked  symptoms  of 
poisoning  by  morphia.  This  promptly  subsided.  April  16,  there 
suddenly  ensued  paralysis  of  the  lower  eyelid  of  the  right  side, 
and  of  the  mnscles  of  the  globe,  the  pupil  being  dilated  and 
not  reacting  to  stimulus,  a  condition  of  diplopia  existing.  The 
patient  died  in  about  a  week. 

The  extirpated  polyp  was  found  to  consist  of  a  firm  connec- 

1  Le  Mouvement  Medicale,  1869,  19,  p.  231. 


310  AFFECTIOlSrS    OF    THE    NASAL    PASSAGES. 

tive-tissue  stroma,  which  contained,  in  its  outer  circumference, 
spaces  covered  with  cylindrical  epithelium,  showing  that  it  was 
an  outgrowth  from  the  glands  of  the  mucous  membrane. 

At  the  autopsy  the  brain  was  found  healthy;  the  meninges 
of  the  right  side  were  richly  supplied  with  blood ;  the  arte- 
ries at  the  base  of  the  cranium  had  undergone  atheromatous 
degeneration.  Several  points  of  pus  on  the  sella  turcica  had 
proceeded  from  the  boue,  which  was  carious  and  readily  per- 
mitted penetration  by  a  probe.  One  of  the  roots  of  the  polyp 
was  inserted  into  this  bone.  The  sinus  cavernosus  was  filled 
with  pus.  The  roots  of  the  polyp  stretched  to  the  smallest  an- 
fractuosities  of  the  nasal  passages,  and  into  the  maxillary  sinus ; 
these  cavities  being  bathed  with  a  mixture  of  mucus  and  pus, 
as  were  also  the  fi-ontal  sinuses,  ethmoid  cells,  and  the  surface 
of  the  cribriform  plate. 

A  polyp  may  become  incrusted  with  calcareous  dejDOsits,  and 
thus  give  rise  to  the  incorrect  diagnosis  of  an  osseous  tumor. 

"VYlien  a  polyp  is  deeply  situated,  and  cannot  be  exjDosed  even 
by  means  of  a  strong  light  thrown  into  the  dilated  anterior 
nares,  we  can  sometimes  thrust  it  forward  by  the  finger,  passed 
■underneath  and  behind  the  palate  into  the  posterior  nasal 
fossse  ;  and,  should  this  fail,  we  may  resort  to  the  ex^Dedient 
adopted  by  M.  Edouard  Fournie,'  who,  in  a  case  of  mucous 
polyp  of  this  kind,  introduced  the  sound  of  Bellocq,  and,  attach- 
ing to  it  a  pledget  of  charpie,  was  enabled  to  force  the  polyp 
forwards,  so  as  to  operate  upon  it  in  a  satisfactory  manner. 

Usually,  however,  by  dilating  the  walls  of  the  nostril  with 
one  of  the  instruments  mentioned  in  the  article  on  examination  of 
the  nasal  cavities,  the  existence  of  a  polyp  can  be  readily  detected. 

The  mucous  or  gelatinoid  polyp  is  sometimes  amenable  to 
the  topical  infiuence  of  astringents ;  but,  as  a  rule,  forcible  ex- 
traction is  required. 

Various  remedies  are  reported  as  capable,  under  favorable  cir- 
cumstances, of  destroying  a  polyp  of  this  kind,  or  inducing  its  ab- 
sorption.    Thus,  we  have  an  instance  recorded"  of  cures  by  the 

'  Gazette  des  Hvpitaux^  1862,  Oct.  11. 

2  {Mecliz.  Chirurg.  Zeitg.  London  Med.  and  Phi/s.  Jour.,  Jan.,  1828);  Am. 
Jour.  Med.  Science,  vol.  ii.,  p.  219. 


TUMORS    IlSr   THE    NASAL    PASSAGES.  311 

saffronized  tincture  of  opium  (Prussian  pharmacopcfiia),  Avliich, 
according  to  Dr.  Primus,  of  Babenhausen,  possesses  the  property 
of  gradually  destroying  nasal  polypi.  A  cure  is  reported, 
among  others  alluded  to,  as  occurring  in  a  case  of  polyp  in  each 
nostril,  in  a  man  forty-six  years  of  age.  The  tincture  was  ap- 
plied, by  means  of  a  hair-j^encil  or  a  roll  of  lint,  to  the  bases 
of  the  o-rowth,  several  times  a  day.  In  eiffht  davs  the  tumors 
had  assumed  a  paler  appearance,  and  lost  a  little  in  volume.  A 
serous  discharo-e  from  the  nose,  wliich  had  existed  for  a  long 
time,  had  diminished,  and  the  pituitary  membrane  had  accpiired 
a  more  lively  tint,  as  if  in  a  sub-inflammatory  state.  The  ap- 
plication was  persisted  in,  the  tumors  continued  to  decrease^  and 
at  the  end  of  three  weeks  had  disappeared  entirely. 

Dr.  Bryant'  extols  the  insufflation  of  pulverized  tannin  to 
destroy  these  polyps,  or  to  modify  the  condition  of  the  mucous 
membrane,  and  has  thus  obtained  permanent  cures.  Six  cases 
are  reported,  in  two  of  which  the  cure  had  been  permanent 
at  the  end  of  one  and  three  years,  respectively.  The  other 
cases  were  more  recent,  and  in  each  one  of  them  several 
operations  had  already  been  performed  for  the  extraction  of 
polyps.  The  duration  of  treatment  varied  from  ten  days  to  a 
month.     Of  late  we  have  heard  little  of  this  remedy. 

Removal  of  Nasal  Polyps. — The  ordinary  method  of  re- 
moving a  pediculated  polyp  from  the  nose  is  by  means  of  torsion 
with  the  forceps.  A  slender  pair  of  polypus-forceps,  slightly 
curved,  with  fenestrated  and  serrated  blades,  much  used  in  this 
country,  is  depicted  in  Fig.  61. 

The  patient  being  placed  so  that  a  strong  light  illumines  the 
nostrils,  with  the  head  supported  if  desired,  the  nostrils  are 
dilated  by  turning  up  the  ti]3  of  the  nose,  or  by  introducing  a 
nostril-dilator.  The  forceps  are  then  passed  up  as  high  as  the 
pedicle  of  the  growth,  which  is  then  fii-mly  grasped  by  the 
blades,  when  the  instrument  is  turned  round  and  round  on  its 
axis  until  the  tumor  is  detached.     Sometimes  a  portion  only  of 

1  {Lancet,  Feb.  23  and  Aug.  24,  1867);  Gaz.  Hebd.,  Oct.  11,  1867,  p.  653. 


312 


AFFECTIOIS'S    OF    THE    IS^ASAL    PASSAGES. 


Fig.  61. 


tlie  growth  comes  away  in  the  instrument,  and  its  reintrodnc- 
tion  is  required  to  detach  the  remainder.  If  several  tumors 
are  present  they  should  all  be  remoTed,  if  pos- 
sible, one  after  the  otlier,  rather  than  to  wait  for  a 
subsequent  occasion.  If  the  bleeding  which  occurs 
obstructs  the  view,  the  parts  are  washed  out  by  the 
syringe,  if  the  patient  cannot  discharge  the  blood 
and  mucus  by  blowing  the  nose.  The  bleeding  is 
not  usually  profuse,  but,  if  it  cannot  readily  be 
restrained  by  astringents,  the  nostrils  can  be 
plugged  with  the  tampon. 

This  process  of  twisting  is  painful,  and  though 
not  as  apt  to  injure  the  mucous  membrane,  or  tear 
off  a  portion  of  the  turbinated  bone,  as  where  the 
polyp  is  forcibly  pulled  from  its  attachments,  this 
accident  occasionally  occurs.  It  may  be  avoided  by 
passing  a  wire  snare  over  the  polyp,  and  cutting 
through  the  pedicle  by  drawing  the  loop  home 
into  the  canula,  or  perforated  rod,  through  which 
it  has  been  passed.  The  instrument  for  this 
purpose  is  similar  to  that  used  for  removal  of 
aural  and  laryngeal  polyps.  The  diflicult  point 
in  the  operation  exists  in  snaring  the  polyp  in  the 
first  instance,  and  then  in  guiding  the  wire  to  the 
base  of  the  .pedicle;  but  it  can  often  be  accom- 
plished. 

Wlien  the  tumor  is  deeply  situated,  or  hangs  loose  behind  the 
palate,  it  may  be  encircled  by  passing  a  long  wire,  doubled  into 
a  loop,  through  the  nostril  into  the  mouth.  The  ends  of  the 
wire  being  held  by  an  assistant,  or  by  the  patient  himself  if  the 
operator  is  unassisted,  the  finger  is  then  carried  behind  the 
palate,  and  the  loop  drawn  out  in  front  of  the  polyp,  after 
which  it  is  pushed  behind  the  mass  so  as  to  encircle  it,  and,  as 
the  wire  is  drawn  out  of  the  nostrils  again,  the  loop  is  pushed 
up  behind  the  polyp  as  far  as  possible.  As  soon  as  it  is  firmly 
in  contact  with  the  pedicle,  the  outer  ends  of  the  wire  are 
passed  through  the  rings,  or  orifices,  of  a  suitable  canula,  and 
attached  to  a  sliding  rod  upon  its  handle.     This  is  then  drawn 


Polj'pus-Forceps. 


TUilOES    IN^   THE    NASAL   PASSAGES.  ^        313 

home  and  the  pedicle  severed.  Care  must  be  taken,  by  keep- 
ing the  finger  npoii  the  polyp,  to  prevent  it  from  falling  do^vn 
upon  the  larynx,  or  into  it.  Some  operators  pass  a  thread 
through  the  polyp  by  which  to  draw  it  out  through  the  mouth. 

Another  method  employed  is  to  pass  the  ends  of  the  wire 
through  a  double  canula,  and  merely  to  strangulate  the  tumor 
without  attempting  to  cut  it  off.  The  ends  of  the  wire  are 
fastened  round  little  rings  at  the  end  of  the  canula,  and  tight- 
ened from  day  to  day  until  the  tumor  drops  o^  In  these 
cases  it  would  be  best  to  pass  a  thread,  if  possible,  through  the 
body  of  the  growth,  and  to  secure  it  to  the  ear,  to  prevent  its 
falling  into  the  pharmx  or  larynx.  Cases  are  on  record  in  which 
tumors  thus  removed  by  the  wire  ho-ve  fallen  into  the  pharynx 
and  been  swallowed. 

Of  late  years,  polyps  of  the  nose  have  been  removed  by  the 
galvanic  cautery.  A  platinum  wire  is  passed  round  the  growth 
and  drawn  home  into  a  double  tube,  the  extremities  of  which 
are  in  contact  with  a  powerful  galvanic  battery.  As  soon  as 
the  mass  has  been  constricted  the  connection  is  closed,  and  the 
tumor  burnt  through.  The  difficulty  in  the  operation  lies  in 
the  adjustment  of  the  snare.  Dr.  Thudichum,^  of  London,  has 
devised  a  special  apparatus  for  this  purpose,  and  commends  the 
treatment  very  highly.  It  is  not  accompanied  with  a  great  deal 
of  pain  or  a  great  deal  of  bleeding ;  but  it  presents  the  objec- 
tion that  it  divides  the  growth  at  the  point  encircled  by  the 
wire,  and  does  not  draw  away  the  pedicle,  as  often  occurs  in  the 
use  of  the  forceps. 

'Wlien  the  polyp,  from  its  large  bulk,  the  diftieulty  of  reach- 
ing its  attachments,  or  from  other  causes,  cannot  be  extracted 
by  means  of  instruments  passed  into  the  nostrils,  an  external 
operation  is  necessary  for  its  removal.  Access  to  the  parts  can 
be  gained  by  the  methods  narrated  in  connection  with  opera- 
tions for  osseous  tumors  in  the  nasal  passages. 

After  removal  of  a  polyp  from  the  nose,  resort  is  made  to  as- 
tringent injections,  frequently  repeated. 

Polyps  of  the  nostrils,  when  removed,  show  great  disposition 

1  On  Polypus  in  th.e  Nose  and  Ozeena.     London,  1869. 


314  AFFECTIOlSrS    OF   THE    JS'A.SAL    PASSAGES. 

to  repullulation,  not  so  mnch,  perhaps,  from  tlie  predisposition 
of  the  parts  to  the  formation  of  the  growths,  but  because  it  is  im- 
possible to  remove  all  the  attachments  of  the  growth  on  account 
of  the  shape  of  the  cavity,  and  these  portions  develop  new  polj^ps 
after  the  extraction  of  the  first  one.  In  this  way  the  subject 
of  nasal  polyp  is  often  compelled  to  undergo  a  series  of  opera- 
tions for  the  removal  of  these  tumors.  Riolan  is  said  to  cite,  in 
his  treatise  on  anatomy,  the  observation  of  an  individual  who 
was  obliged  to  submit  to  an  operation  of  this  kind  every  month, 
for  forty  consecutive  years. 

Prof.  Gross '  recommends,  in  cases  where  there  is  great  ten- 
dency to  regeneration  of  polyps,  or  where  they  exist  in  great 
numbers,  the  removal  by  forceps  of  half,  or  even  more,  of  the 
implicated  turbinated  bone ;  a  procedure  which  he  has  some- 
times adopted,  and  which  he  believes  preferable  to  the  frequent 
repetition  of  the  ordinary  operation. 

A  Neurilemmatous  Tumor  occasionally  develops  in  the 
nostril,  and  is  liable  to  be  mistaken  for  ordinary  polyp.  A 
case  of  this  kind  was  reported  by  the  Sig.  del  Greco  as 
having  occurred  in  the  Hospital  of  Pisa.^  A  man,  set.  25, 
had  for  about  six  months  been  affected  with  an  obstruction  in 
the  left  nostril,  and  swelling  of  the  left  cheek.  On  examina- 
tion it  was  ascertained  that  a  polypous  tumor  had  formed  in 
the  left  nostril ;  and  this  it  was  decided  to  extract,  but  the  sur- 
geon was  unable  to  remove  it  A  few  months  afterwards  another 
attempt  was  made,  but  with  no  better  success.  The  patient  com- 
plained of  violent  pain  during  the  operation,  and  said  he  felt  as  if 
the  left  ear  and  cheek  were  being  torn  off.  A  few  hours  after 
the  second  operation  an  inflammatory  swelling  of  the  left  cheek 
occurred,  but  subsided  on  the  following  day.  Subsequently,  a 
third  attempt  was  made  to  extract  the  tumor,  but  without  any 
effect.  Soon  after  the  third  operation  symptoms  of  arachnitis 
took  place,  of  which  the  patient  died  on  the  tenth  day.  On 
post-mortem  examination,  unequivocal  traces  of  inflammation 

^  System  of  Surgery. 

2  {Ann.  di  Med.  Fase.,  Feb.,  1839?  1830?);  Am.  Jour.  Med.  Sei.,  1831,  p. 
227. 


TUMORS    IN   THE    NASAL    PASSAGES.  315 

were  found  in  the  brain  and  its  membranes.  The  tumor  in  the 
nostril  was  seated  in  a  branch  of  the  fifth  pair  of  nerves  in  the 
following  manner :  the  second  branch  of  the  fifth  pair,  imme- 
diately after  its  passage  through  the  foramen  rotundum,  was 
converted  into  a  fibrous  mass,  divided  into  five  lobes,  two  of 
which  were  of  the  size  of  a  peach-stone ;  the  three  others  being 
smaller,  and  one  of  them  reaching  into  the  orbit  through  the 
spheno-maxillary  fissure.  The  fibrous  tumor  was  situated  in 
the  temporal  fossa,  between  the  zygomatic  process  and  the 
great  wing  of  the  sphenoid  and  the  upper  maxillary  bone ;  the 
spheno-palatine  foramen  had  become  greatly  enlarged,  so  as  to 
admit  the  little  finger,  and  through  it  the  tumor  had  entered 
the  nasal  cavity,  where  it  had  acquired  such  a  development  as 
to  resemble  a  polypous  growth.  On  dissecting  the  tumor  it 
was  found  to  originate  in  the  neurilemma,  and  not  in  the  sub- 
stance of  the  nerve,  which  was  not  at  all  altered,  except  by  the 
pressure  which  had  been  exerted  on  it  by  the  enlargement  of 
the  neurilemma. 

Adenomas  of  the  pituitary  glands  occur.  A  case  presenting 
in  a  female,  £et.  63,  occupied  the  superior  and  anterior  portion 
of  the  nasal  fossse  of  the  left  side.  Prof.  Yerneuil  ^  operated. 
The  nostril  was  tamponed  front  and  back,  and  the  parts  then  re- 
moved under  chloroform  •  access  being  gained  by  a  Y  incision, 
practised  in  the  sub-orbital  and  nasal  regions."  The  dorsal  de- 
cubitus was  preserved  during  the  operation,  with  the  face  slight- 
ly inclined  towards  the  injured  side,  so  that  the  blood  could 
fiow  oft"  upon  the  cheek  and  not  interfere  with  the  operation. 

Malignant  Tumors  involving  the  Nasal  Fossae. — An  ex- 
amination of  the  recorded  cases  shows  that  malignant  disease 
involving  the  nasal  fossse  usually  originates  outside  of  them. 
An  epithelioma  which  will  eventually  involve  the  nasal  fossse, 

1  ArcJdves  Qenerales^  Oct.,  1870,  p.  390:  for  details,  see  inaugural  thesis 
of  Pugliese,  Essai  sxir  les  AcUnomes  des  Fosses  Nasales.  Paris,  15  avril,  1862, 
p.  8  et  seq. 

^  A  second  growth  appeared  some  time  after,  and  was  removed  by  Dr.  Bas- 
tien. 


316  AFFECTIOT^S    OF   TIIE    NASAL    PASSAGES. 

maxillary  sinns,  frontal  sinus,  orbit,  and  other  strnctnres,  will 
begin,  as  in  Yerneuil's  case,'  by  a  subcutaneous  tumor  connected 
with  the  bone,  and  in  all  likelihood  involving  it — in  this  instance 
situated  a  little  in  fi-ont  of  and  below  the  sub-orbital  foramen. 
In  four  months  it  acquired  an  immense  bulk.  Patient  a  coun- 
tryman, 9et.  60. 

The  disease  will  involve  the  nasal  bones,  os  unguis,  ethmoid 
bone,  and  other  structures. 

Prof.  YerneuiP  records  a  case  of  epithelioma  of  the  inferior 
eyelid,  which  during  two  years  invaded  successively  the  cheek, 
lateral  face  of  the  nose,  the  conjunctiva,  and  the  upper  eyelid, 
penetrating  into  the  orbit,  the  nasal  fossae,  and  the  maxillary 
sinus,  occurring  in  a  female  concierge,  set.  54  and  married. 
In  the  performance  of  the  operation  it  was  necessary  to  sacri- 
fice largely  the  integuments  of  the  visage;  and  at  the  same  time 
a  portion  of  the  skeleton  of  the  nose  and  the  nasal  fossae.  The 
parts  were  tamponed  and  the  patient  chloi'oformed.  The  en- 
tire cheek  was  removed,  the  globe  of  the  eye,  the  two  eyelids, 
the  greater  portion  of  the  superior  maxillary  and  ethmoid  bones 
of  the  left  side;  and  all  without  more  solicitude  and  difficulty 
than  usually  accompany  the  extirpation  of  a  superficial  can- 
croid. The  patient  recovered  promptly  and  gained  her  ordi- 
nary embonpoint  and  general  strength,  so  that  the  j)roject  was 
entertained  of  performing  a  plastic  operation  to  remedy  the  de- 
formity. This  apparent  cure  continued  an  entire  year,  when  a 
return  of  the  disease  manifested  itself  by  the  side  of  the  tem- 
poral fossa,  and  slowly  produced  death  without  the  accompani- 
ment of  any  severe  distress. 

Osseous  Tumors  of  the  Nasal  Fossae. — Osseous  tumors 
are  sometimes  developed  in  the  nasal  passages,  and  in  the 
sinuses  communicating  with  them.  My  main  source  of  infor. 
mation  on  this  subject  has  been  derived  from  an  admirable 
little  pamphlet  written  by  Dr.  Paul  Olivier,  one  of  the  Parisian 


1  Arch.  Gen.,  Dec,  1870,  p.  394. 

2  Archives  Generales,  Oct.,  1870,  p.  390. 


TUMOES    IN    THE    NASAL    PASSAGES.  317 

hospital  surgeons,  and  published  in  Paris,  1869,  entitled  "  Sur 
les  Tumeurs  Osseuses  des  Fosses  Nasales  et  des  Sinus  de  la 
Face ; "  and,  in  the  absence  of  much  other  material,  I  have 
drawn  very  largely  on  its  pages  for  what  follows. 

Dr.  Olivier  distinguishes  the  tumors  treated  of  in  this  essay 
from  other  solid  tumors  which  occupy  the  nasal  cavities,  by 
two  cliaracteristics : — 

1st.  They  contain  in  their  anatomic  constitution  only  the  ele- 
ments of  osseous  tissue,  spongy  or  compact. 

2d.  They  are  primitively  developed  in  the  fibro-mucous 
meinbrane  which  lines  the  cavities  of  the  nasal  fossae  and  the 
sinus. 

These  two  characteristics,  the  intimate  nature  and  the  spe- 
cial seat,  enable  him  to  reject  from  his  descriptions  polyps 
enclosing  osseous  concretions  or  simply  calcareous  concretions  ; ' 
ossihed  sarcomas ;  those  tumors,  as  yet  but  little  studied,  com- 
posed of  cartilage  and  bone,  like  those  which  Messrs.  Trelat 
and  Dolbeau  have  presented  to  the  Societe  de  Chirurgie ;  ^  those 
tumors,  described  under  the  name  of  syphilitic,  scrofulous,  or 
othei-  exostoses,  which  have  their  point  of  departure  in  the  bone 
itself  and  in  the  osseous  walls  of  the  sinus. 

These  and  still  other  tumors  occurring  in  the  same  situation 
are  e\idently  developed  in  the  bones  of  the  face,  and  are  the 
result  of  the  various  diseases  of  these  bones ;  wliile  the  tumors 
about  to  be  described  are  all  of  one  and  the  same  nature. 
They  are  developed  in  the  internal  periosteum  of  the  sinus ; 
the  bone  in  their  neighborhood  is  not  diseased,  and  if  it  be- 
comes diseased  at  a  later  period  it  is  not  because  it  is  invaded 
by  the  tumor ;  it  is  absorbed,  modified  in  its  nutrition  as  we  see 
it  become  absorbed,  inflamed  sometimes  by  the  contact  of 
aneurism ;  it  suffers,  in  both  cases,  a  similar  influence  of  conti- 
guity. 

M.  Dolbeau  encountered  a  case  in  186-1,  at  I'Hotel-Dieu,  and 
having  collected  the  observations  j)i'eviously  published,  read 
a  memoir  at  the  Academic  de  Medecine,  in  September,  1866, 

1  Gazette  Medicale,  1868.    Fibrome  calcifie,  observed  by  M.  Bourdilliat. 
^  BuUetins  de  ko  Societe  de  Chirurgie^  1862,  p.  261. 


318  AFFECTIOISrS    OF   THE    NASAL    PASSAGES. 

the  conclusions  alone  of  which  have  been  published  in  the  Bul- 
letin de  V Academie  de  Medecirie,  tome  xxxi,  p.  1076,  1865- 
1866,  and  which  are  given  in  the  pamphlet  of  Dr.  Olivier. 
They  are : — 

1.  The  Schneiderian  membrane,  which  covers  the  different 
sinuses  and  cellules  communicating  with  the  nasal  fossse,  may 
become  the  seat  of  primitive  osseous  productions,  tumors  which 
are  independent  of  the  bones  of  the  skull  and  those  of  the  face, 
but  which  may,  nevertheless,  acquire  a  very  great  bulk. 

2.  We  may  append  to  these  diverse  ossifications  the  exostosis 
removed  by  M.  Michon  in  the  maxillary  sinus ;  exostoses  of 
the  orbit  arising  from  the  ethmoidal  cells ;  the  osseous  tumor 
taken  from  a  nasal  fossa  by  M.  Legouest;  the  tumors  observed 
by  M.  Cloquet,  and  which  he  has  described  as  ossifications  of 
mucous  polyps  of  the  nasal  fossae ;  aud,  also,  the  recent  case  of 
M.  Pamard. 

3.  The  membrane  which  lines  the  frontal  sinus  does  not  form 
any  exception,  and  sometimes  becomes  the  seat  of  exostosis; 
such  are  the  cases  of  Otto,  E.oux,  Jobert  (de  Lamballe),  Holmes, 
Coote,  and  Dolbeau. 

4.  All  these  exostoses  are  alwaj-s  more  or  less  free  in  the 
cavities  in  which  they  have  originated ;  they  may,  in  their  de- 
velopment, become  more  or  less  solidly  wedged,  but  they  alwajs 
remain  independent  of  the  bone,  and  they  may  be  removed  pro- 
vided a  sufficient  opening  can  be  made  for  that  purpose  ;  hence 
the  indication  for  an  early  operation. 

5.  The  exostoses  of  the  frontal  sinus  in  particular  form  no 
exception,  and,  despite  their  vicinity  to  the  brain,  these  tumors 
may  be  enucleated.  The  development  of  these  tumors  being 
indefinite,  it  is  wise  to  operate  as  soon  as  there  is  no  doubt  of 
their  presence,  in  order  to  avoid  their  propagation  into  the  cra- 
nial cavity. 

6.  In  the  treatment  of  all  these  exostoses  it  is  necessary  to 
renounce  a  direct  attack  upon  the  tumor,  whether  with  the 
gouge  or  the  trepan.  None  of  these  instruments  can  cut  a 
tissue  so  hard  ;  they  become  blunt,  and  the  best  cutting-pliers  of 
Liston  have  been  seen  to  break  without  making  any  impression 
uj)on  the  tumor.     It  is  necessary,  as  has  already  been  said,  to 


TUMOES    IN    THE    NASAL    PASSAGES.  319 

open  largely  the  cavity  containing  the  exostosis,  and  it  then 
sufhces  to  move  the  entire  mass  of  the  tumor  from  side  to  side, 
to  see  it  come  away  in  totality,  and  without  any  great  effort. 

This  article  was  referred  to  the  examination  of  a  committee, 
composed  of  MM.  Yelpeau,  Gosselin,  and  Richet. 

In  February  and  July,  1869,  two  new  cases  presented  them- 
selves in  the  service  of  Professor  Hichet ;  their  observation,  from 
notes  taken  at  the  bedside,  and  at  the  clinics  which  Professor 
Richet  made  them  the  occasion  of,  forms,  with  that  communi- 
cated to  him  by  M.  Dolbeau,  the  bases  of  M.  Olivier's  pam- 
phlet. In  addition  to  these  cases,  he  has  collected  some  from 
the  records  of  other  surgeons,  making  eleven  in  all. 

The  size  of  these  tumors  varied  from  that  of  a  nut  to  that  of 
an  apple;  their  weight,  from  fifteen  grammes  to  one  hundred 
and  twenty  grammes.  The  subjects  operated  upon  were  of  both 
sexes,  and  all  young,  their  ages  ^'arying  from  thirteen  years  to 
thirty-four.  In  all  of  them  the  disease  seemed  to  have  made  its 
appearance  early ;  on  the  average,  between  the  ages  of  fifteen 
and  twenty.  They  were  slow  in  growth,  sometimes  remaining 
quiescent  for  years,  and  then  suddenly  taking  on  a  fresh  develop- 
ment. As  they  increase  in  size  they  produce  great  deformity  of 
the  visage,  dislocating  the  eyeball  if  in  proximity  to  the  orbit, 
and  inflict  a  great  deal  of  pain.  The  symptoms  they  produce 
are  at  first  ill-defined,  being  such  as  attend  inflammations,  polyps, 
and  otlier  tumors ;  sometimes  nothing  but  a  seiise  of  weight  and 
numbness  in  the  parts.  At  other  times  they  provoke  pains  re- 
ferred to  the  teeth,  if  the  maxillary  sinus  be  implicated,  or  to 
supra-orbital  neuralgia  if  it  be  in  the  frontal  sinus.  There  is 
also  apt  to  be  epistaxis  without  any  appreciable  cause.  At  a 
later  date,  when  the  tumor  is  increasing  in  size,  the  more  posi- 
tive symptoms  are  produced.  The  pain  varies  in  character, 
from  occasional  intermittent  pangs  at  long  intervals,  to  involve- 
ment of  all  the  branches  of  the  fifth  pair  of  nerves,  and  is  most 
frequently  due  to  compression  of  the  nervous  filaments,  and  is 
not  always  proportionate  to  the  size  of  the  tumor,  depending 
rather  upon  the  resistance  which  the  neighboring  parts  offer  to 
its  development,  and  upon  the  more  or  less  rapid  march  of  the 
affection. 


320  AFFECTIONS    OF   THE   NASAL    PASSAGES. 

Wlien  the  tumor  has  attamed  a  sufficient  size  it  can  be  dis- 
tinguished from  the  exterior  ;  and  about  this  period  the  hemor- 
rhages usually  cease.  At  first  they  are  thought  to  be  due  to  the 
congestion  of  the  mucous  membrane,  produced  by  the  presence 
of  the  tumor.  Sometimes  they  are  sjiontaneous,  or  due  to  ulcer- 
ation of  the  mucous  membrane ;  at  other  times  occur  only  when 
the  ]Datient  picks  his  nose,  or  when  the  surgeon  examines  the 
tumor,  under  which  latter  circumstance  it  is  sometimes  very 
profuse.  ■ 

When  the  tumor  occupies  the  nasal  fossae,  it  is  usually  more 
appreciable  than  when  it  is  developed  in  the  sinuses.  It  is  gen- 
erally seen  at  the  anterior  portion  of  the  nostrils,  colored  red 
when  still  covered  with  raucous  membrane,  or  grayish  if  it  has 
become  carious,  as  in  one  of  the  cases  reported.  It  may  be 
touched,  directly  by  the  linger,  and  without  interposition  of  any 
other  tissue.  If  it  is  in  the  frontal  or  maxillary  sinus,  there  is 
always  more  or  less  covering  by  the  soft  tissues,  which  prevents 
an  exact  appreciation  of  its  physical  properties.  Sometimes, 
however,  the  integuments  undergo  ulceration  and  are  destroyed, 
so  that  the  tumor  is  directly  exposed  to  vision.  In  all  the 
observations  exophthalmos  existed,  whatever  had  been  the  prim- 
itive seat  of  the  tumor.  Other  displacements  and  consecutive 
aifections  of  the  eye  are  often  produced,  varying  with  the  seat 
and  form  of  the  growth ;  such  as  inability  to  close  the  lids  over 
the  eye,  oedema  of  the  eyelids,  strabismus,  conjunctivitis,  che- 
mosis,  inflammation  and  ulceration  of  the  cornea,  etc. 

There  are  troubles  of  respiration,  phonation,  and  mastication. 

Whatever  may  be  the  seat  of  the  tumor,  it  has  always  the 
same  characters — immobility  or  obscure  mobility,  osseous  hard- 
ness in  its  entire  extent.  Its  surface  may  be  uniform  or  nodu- 
lated, the  latter  being  a  special  symptom  of  the  eburnated 
variety.  The  texture  of  the  tumor  is  judged  of  by  the  touch  of 
the  finger  and  by  the  use  of  the  exploring  needle,  which  cannot 
be  made  to  penetrate  it  except  in  certain  cases  of  tumors  of 
cancellated  tissue,  where  it  is  possible  to  hit  upon  one  of  the  in- 
terspaces limited  by  the  osseous  columns  of  the  tumor;  and 
therefore  the  needle  should  be  applied  several  times. 

In  the  nasal  cavity  the  tumor  is  readily  examined,  either  ante- 


TUMORS    IE"    THE    ISTASAL    PASSAGES.  321 

riorly  or  with  the  finger  passed  behind  the  palate,  where  it  may 
sometimes  be  felt,  generally  separated  from  the  pharynx  by  a 
greater  or  less  free  space.  If  the  tumor  has  become  denuded  of 
its  periosteum,  it  provokes  ulceration  of  the  mucous  membrane, 
abscess,  and  a  discharge  of  sanious  fluids  which  poison  the 
patient  by  their  odor,  and  by  being  swallowed  with  the  saliva. 
In  these  cases  the  examination,  even  when  conducted  with  great 
care,  sometimes  produces  serious  hemorrhage.  This  loss  of 
blood,  sup]juration,  and  poisoning,  induce  hectic  fever,  loss  of 
appetite,  and  so  on,  under  the  influence  of  which  the  patient 
will  snccumb,  if  not  promptly  relieved  by  surgical  operation. 

These  tumors  are  not  removable  by  direct  attack.  The  ebur- 
nated  variety  cannot  be  broken  or  cut  by  instruments,  and  it  is 
necessary  to  prepare  a  passage  from  the  exterior  large  enough 
to  admit  of  their  being  extracted  in  bulk.  The  cellulous  tumors, 
on  the  other  hand,  are  so  friable  that  they  almost  always  break 
in  the  grasp  of  the  instrument  when  an  attempt  is  made  to  ex- 
tract them  in  bull^:.  For  the  one  variety,  therefore,  a  very  large 
exterior  passage  is  required,  and  for  the  other  a  smaller  exposure 
sufiices.  When  the  friable  tumors  occupy  the  nasal  passages,^ 
it  is  suggested  by  M.  Ollivier  that  an  attempt  be  made  to  crush 
them,  and  remove  them  in  fragments,  before  resorting  to  any 
mutilation  of  the  soft  parts. 

If  the  tumor  occupy  the  frontal  sinus,  or  ethmoidal  cells,  it  is 
recommended  by  Richet  to  expose  it,  if  small,  by  an  incision 
slightly  convex  above,  immediately  beneath  the  eyebrow ;  and 
if  large,  by  two  incisions,  meeting  at  a  right  angle,  as  practised 
by  Dolbeau  and  Maisoimeuve,  The  borders  of  the  osseous 
tissues,  which  form  a  sort  of  collar  about  it,  are  then  to  be  re- 
sected, when  the  tumor  can  be  seized  with  forceps,  and  removed 
by  a  dislodging  motion  to  one  side  and  the  other.  In  one  case, 
M.  Bouyer,  in  order  to  remove  two  exostoses  from  his  patient, 
broke  the  anterior  plate  of  the  frontal  bone  to  get  at  one,  and 
was  obliged  to  saw  the  superior  portion  of  the  orbitary  ridge 
to  get  at  the  other. 

If  the  tumor  occupy  the  nasal  fossa,  it  has  been  recommended 

by  Lenoir  to  make  an  incision  in  the  middle  of  the  nose,  from 

its  base  to  its  point;  and  by  Legouest  and  Richet  to  make  a 
21 


322  AFFECTIONS    OF   THE    IN^ASAL    PASSAGES. 

curvilinear  incision  from  the  angle  of  the  eye  to  the  border  of 
the  lip.  The  flaps  being  dissected,  Richet  and  Lenoir  were  able 
to  extract  the  tumor  bj  resecting  the  nasal  bone  of  the  side  it 
occupied.  In  the  case  of  Legouest  there  was  a  species  of  con- 
striction in  the  middle  of  the  tumor  that  rendered  its  extrac- 
tion more  difiicult.  He  was  oblio;ed  to  make  a  fresh  incision, 
perpendicular  to  that  already  made,  and  then  to  make  a  tempo- 
rary resection  of  the  superior  maxilla  in  order  to  reach  the 
postel'ior  portion  of  the  tumor,  which  had  broken  into  two  frag- 
ments. 

"Wlien  the  tumor  has  been  extracted,  the  cavity  in  which  it 
was  lodged  is  to  be  examined;  any  roughnesses  that  may  be 
due  to  former  attachments  of  the  tumor  must  be  scraped  off, 
and  any  polyps,  which  are  apt  to  coexist  with  the  osseous  tumor, 
are  to  be  removed.  If  the  external  wound  has  been  extensive, 
it  is  united  by  suture ;  otherwise  its  edges  are  merely  placed  in 
apposition,  a  free  opening  being  maintained  for  the  passage  of 
the  products  of  suppuration,  which  is  almost  inevitable. 

Recovery  is  usually  rapid,  sometimes  without  any  untoward 
circumstance  whatever.  In  other  cases  fever,  vomiting,  erysipe- 
las, and  cerebral  disturbance  retard  the  convalescence. 

As  far  as  present  observations  go  (1869)  there  has  been  no 
return  of  the  tumors  thus  removed. 

An  interesting  example  of  exostosis,  involving  the  nasal  cavity 
in  connection  with  the  orbit,  successfully  operated  upon  by  Dr. 
Alex.  B.  Mott,^  of  ISTew  York,  may  be  alluded  to  in  this  connec- 
tion. The  patient  was  a  man  thirty-three  years  of  age,  and  had 
been  affected  for  some  seven  years.  The  growth  began  as  an 
enlargement,  towards  the  inner  canthus  of  the  left  eye,  at- 
tended with  inflammation  and  lachrymation.  Previous  to 
this  the  general  health  of  the  patieiit  had  been  good,  except 
that  he  had  been  subject  to  headache.  In  eighteen  months 
the  left  nostril  became  closed  up.  Though  he  applied  to 
surgeons  for  relief,  nothino^  essential  was  done  until  he  came 
under  the  care  of  Dr.  Mott;  the  tumor,  in  the  mean  time, 
having  increased    in    size,   and    pressed    the    eye    outwards. 

1  Am.  Jour.  Med.  yScj. ,  Jan.  1857,  p.  35  (illustrated). 


TAMPONING    THE    NASAL    PASSAGES.  323 

Two  months  previous  to  this  time  a  hemorrhagic  discharge 
had  taken  place  from  the  left  nostril,  and  continued  sub- 
sequently, night  and  day,  to  a  considerable  extent.  A  month 
after  this  an  abscess  formed  under  the  lower  lid,  towards  the 
inner  canthus ;  and  through  an  opening  at  this  point  the  bone 
could  be  distinctly  felt  with  a  probe,  and  its  existence  in  the 
nostril  was  equally  evident.  Several  polypi  existed  in  the  oppo- 
site nostril,  and  were  removed  before  the  main  operation  was 
undertaken. 

The  operation  began  with  an  incisicm  from  the  ala  of  the 
nose,  in  a  direct  line  upwards,  to  about  half  an  inch  above  the 
superciliary  ridge,  followed  by  a  transverse  incision  from  the 
centre  of  the  upper  eyelid,  across  the  nasal  bone,  to  the  opposite 
eyelid,  terminating  in  a  line  with  the  inner  canthus  of  the  eye. 
The  four  flaps  were  then  dissected  up.  On  raising  the  flap 
nearest  the  nose,  it  was  evident  that  a  large  portion  of  the  osse- 
ous mass  extended  into  the  nasal  cavity,  and  it  became  neces- 
sary to  remove  the  whole  of  the  fleshy  portion  of  the  nose  from 
the  nasal  bone  of  that  side.  The  nasal  bone  was  then  separated 
from  its  fellow  by  a  strong  pair  of  Liston's  forceps,  and  from 
the  frontal  bone  by  a  fine,  straight  flexible  saw.  A  large  por- 
tion of  the  mass  was  then  removed  by  manipulation,  and  the 
remainder  cliiselled  from  the  orbital  plates  of  the  frontal  and 
upper  maxillaiy  bones,  the  os  unguis  being  so  thoroughly  incor- 
porated with  the  mass  as  to  require  removal  with  it,  extraction 
being  accomplished  by  slight  traction  with  strong  forceps.  The 
wfeight  of  the  tumor  was  three  ounces  and  one  drachm.  Ery- 
sipelas and  fever  set  in,  but  were  happily  subdued,  and  the 
patient  made  a  prompt  and  satisfactory  recovery. 

TAilPONING  THE  POST-NASAI.  FOSS^. 

In  operating  on  diseases  of  the  nasal  region  the  tampon  should 
be  employed  before  anaesthetizing  the  patient.  If  the  anajsthetic 
is  administered  first,  there  may  be,  as  reported  in  one  of  Prof. 
Yerneuil's  cases,  great  difiiculty  in  tamponing ;  the  jaws  may 
be  hard  to  separate ;  the  tongue  is  apt  to  be  contracted  by  the 
irritation  of  the  canula,  and  force  itself  upwards  and  back- 
wards so  as  seriously  to  embarrass  the  manipulation. 


324  AFFECTIOI^S    OP    THE    NASAL    PASSAGES. 

Wlien  the  occlusion  is  perfect,  so  that  no  blood  escapes  into 
the  throat,  the  patient  remains  perfectly  quiet  during  the  opera- 
tion, without  any  elevation  of  pulse,  or  irregularity  of  respiration. 
If  the  occlusion  is  imj^erfect,  or  becomes  so  during  the  opera- 
tion, the  escape  of  even  a  small  amount  of  blood  into  the  throat 
will  induce  reflex  action,  which  will  at  once  accelerate  the 
pulse,  thereby  increasing  the  flow  of  blood,  and  interfere  with 
respiration,  or  even  suspend  it. 

Anaesthesia  is  recommended  in  the  performance  of  these 
operations,  because  the  agitation  of  the  patient,  his  cries,  etc., 
produce  a  vascular  turgescence  of  the  parts,  which  increases 
the  amount  of  hemorrhage  ;  therefore,  under  the  influence  of 
insensibility,  there  is  a  much  less  amount  of  blood  lost. 

The  entrance  of  blood  into  the  throat  provokes  nausea,  vomit- 
ing, expectoration,  and  a  variety  of  movements  which  produce 
turgescence,  and  thus  tend  to  increase  the  hemorrhage. 

After  bleeding  has  ceased  the  tampon  should  be  removed, 
lest  its  presence  excite  irritative  inflammation. 

If  the  septum  narium  is  perforated,  it  will  be  necessary  to 
tampon  both  the  nasal  fossae,  though  the  operation  to  be  per- 
formed concern  but  one  of  them. 


ArFECTIOjS"S    OF    THE    FEOIN'TAL    SESTUS.  325 


CHAPTEK   XIIL 

AFFECTION^S    OF   THE    FRO:S"TAL    SINUS. 

The  froutal  sinus  is  liable  to  become  the  seat  of  varions  affec- 
tions ;  but  most  of  these  occur  very  infrequently,  and  the  little 
that  is  known  concerning  them  is  to  be  gathered  principally 
from  isolated  reports  in  the  journals  or  in  special  monographs. 
Some  of  these  affections  are  apt  to  be  continuous  with  affections 
of  the  nasal  canities,  or  dependent  upon  them.  Others  appear 
to  originate  in  the  sinus. 

Inflammation  occurs,  sometimes  as  a  result  of  external  in- 
jury, more  frequently  by  reason  of  an  extension  of  disease  from 
the  nasal  cavities,  principally  in  connection  with  tertiary  syphilis. 
This  produces  pain,  a  sense  of  fulness  in  the  parts,  and  moi'e  or 
less  serous  or  mucous  discharge  from  the  nostrils.  A  moderate 
degree  of  inflammation  of  the  frontal  sinus  attends  severe  cases 
of  coryza. 

This  is  to  be  combated  by  the  ordinary  treatment  for  inflam- 
mation, means  being  taken  to  promote  the  discharge  from  the 
nasal  passages. 

Frequent  attacks  of  this  kind  sometimes  result  in  permanent 
distention  of  the  frontal  sinuses,  wdiich  become  markedly  prom- 
inent, accompanied  by  chronic  purulent  or  muco-purulent  dis- 
charge from  the  nose,  which,  when  fetid,  forms  one  of  the  most 
obstinate  varieties  of  ozoena,  on  account  of  the  profuse  secretion 
of  the  purulent  matter,  and  the  clifliculty  in  reaching  its  source 
by  local  remedies.  Forcible  injections,  by  means  of  a  long  syringe 
passed  high  up  the  nostril,  sometimes  penetrate  into  the  sinuses, 
and  usually  give  rise  to  intense  pain  in  the  frontal  region,  some- 
times lasting  for  hours.  The  use  of  the  nasal  douche  in  cases  of 
chronic  discharge  from  the  nasal  cavities  also,  at  times,  admits 
the  passage  of  the  fluid  into  the  frontal  sinuses,  and  thus  pro- 
vokes severe  pain,  necessitating  an  abandonment  of  the  opera- 
tion. 


326  AFFECTIOIS^S    OF   THE    FEOXTAL    SINUS. 

The  local  effects  of  ointments,  apj^liecl  fi-eely  to  the  nasal 
mucous  membrane,  is  sometimes  propagated  by  continuity  to 
the  lining  membrane  of  the  sinuses,  and  thus  enables  us  to  con- 
trol the  pain  in  the  part.  I  have  found  an  ointment  of  simple 
cerate,  or  lard,  in  which  two  or  three  grains  of  sulphate  of 
morphia  to  the  ounce  has  been  well  incorporated,  do  excellent 
service  in  some  painful  affections  of  the  frontal  sinus. 
.  An  alDscess  sometimes  forms  in  the  frontal  sinus  as  a  result 
of  inflammation,  and  finds  its  way  into  the  nose,  and  even,  in 
some  instances,  penetrates  the  anterior  wall  of  the  sinus.  Ery- 
sipelatous inflammation  of  the  soft  parts  overlying  the  sinus, 
with  great  local  and  general  disturljance,  would  usually  be  in- 
dicative of  the  formation  of  an  abscess ;  under  which  circum- 
stances it  is  recommended  to  cut  down  upon  the  parts,  and  enter 
the  sinus  b}^  means  of  a  small  trephine,  in  order  to  discharge 
the  abscess. 

In  some  instances  a  drainage-tube  is  left  in  the  parts ;  in 
other  instances  a  ^^erf oration  is  made  into  the  nasal  cavity,  and 
the  drainage-tube  passed  through  it,  in  order  to  favor  the  pas- 
sage of  the  secretions  by  that  channel.  At  other  times  the  in- 
terior of  the  cavity  is  washed  out  by  warm  astringent  anodjme 
or  detergent  lotions. 

When  the  abscess  occurs  in  the  course  of  syphilis,  there  is 
danger  of  caries  of  the  bone  and  penetration  into  the  cavity  of 
the  cranium. 

Dr.  Soelberg  Wells  {Lancet^  May  14,  1870)  records  the  fol- 
lowing case  of  abscess  of  the  frontal  sinus.  R.  S.,  a  baker,  set. 
40,  had  about  twelve  years  before  a  tumefaction  of  the  upper 
eyelid  of  the  right  side,  wliich  disappeared  spontaneously  at  the 
end  of  a  week,  but  reappeared  about  every  two  years.  For  the 
past  six  months,  the  patient  had  noticed  at  the  side  of  this  tume- 
faction of  the  eyelid  a  tumor  situated  in  the  internal  angle  of 
the  orbit,  near  the  root  of  the  nose ;  which,  augmenting  pro- 
gressively, induced  the  patient  to  present  himself  at  King's 
County  Hospital,  June  14,  1869. 

Disease  of  the  mucous  lining  of  the  frontal  sinus  may  give 
rise  to  the  deposit  of  calcareous  concretions,  such  as  are  met 
with  in  the  nasal  cavities.     The  larvae  of  insects  are  sometfmes 


TUMOES    OF    THE    FRONTAL    SINUS.  327 

found  in  the  frontal  sinus  from  the  development  of  eggs  which 
have  been  deposited  in  the  nasal  passages,  one  or  two  instances 
of  which  are  given  in  connection  with  the  subject  of  diseases 
of  the  nasal  passages.  Other  foreign  bodies  are  occasionally 
found  in  this  situation,  sometimes  pushed  up  through  the  nose, 
sometimes  the  result  of  gunshot  or  other  injury,  or  of  ordinary 
fracture.  The  indication  would  be,  in  the  case  of  a  foreign 
body,  to  expose  it  by  external  incision  and  the  trephine,  in 
order  to  accomplish  its  extraction. 

An  occlusion  of  the  passage  between  the  sinus  and  the  nasal 
cavit}^  causes  accumulation  of  mucus,  pus,  and  sometimes  blood, 
eventuating  in  marked  distention  of  the  parts,  sometimes  pro- 
ducing deformity  of  the  eyeball.  Under  such  circumstances 
there  may  be  danger  of  pressure  on  the  brain,  or  of  perforation 
into  the  cavity  of  the  cranium.  Prompt  evacuation,  through 
the  nose  or  externally,  is  required  under  this  condition. 

Tumors  of  the  Frontal  Sinus. — Yarious  tumors  occur  in 
connection  with  the  frontal  sinus.  These  may  be  polyps,  simi- 
lar to  those  in  the  nasal  cavity,  cystic  tumors,  osseous  tumors, 
and  malignant  growtlis.  Their  diagnosis  is  not  easy  until  by 
their  develojDment  they  have  produced  a  characteristic  deform- 
ity. 

The  symptoms,  nature,  and  treatment  of  these  tumors  will 
be  made  evident  by  the  subjoined  cases  selected  in  illustration. 

Cystic  Tumor  of  Frontal  Shius.  A  case  of  this  kind,  occur- 
ring in  the  practice  of  Prof.  Jaeger,  is  reported '  by  J.  W.  Brunn. 
A  delicate  girl,  nine  years  of  age,  affected  with  severe  headache, 
had  a  swelling  in  the  left  eyebrow,  gradually  followed  by  im- 
paired sight  of  the  adjoining  eye.  At  fourteen  j^ears  of  age 
she  was  first  examined  l)y  Prof.  Jaeger,  who  found  a  hard 
tumor  which  could  be  indented  by  digital  pressure,  upon  the 
removal  of  which  it  resumed  its  original  appearance.  The  ante- 
rior plate  was  divided,  giving  exit  to  a  large  quantity  of  bloody 
sei'um,  and  the  cavity  of  the  sinus  was  found  divided,  by  delicate 
membranes,  into  numerous  cells.     Under  the  impression  that 

^  {Becker's  A7inalen,  Mch.  1829).     A7n.  Jmir.  Med.  /Sci,  vol.  5,  p.  203. 


328  AFFECTIOiSrS    of    the    FEOIN'TAL    SINUS. 

the  tninor  involved  the  inner  table  of  the  frontal  bone,  it  was 
not  further  disturbed.  Violent  inilanunation  ensued,  attended 
with  a  discharge  of  offensive  serum.  The  discharge  ceased,  the 
opening  healed,  and  the  turnor  remained  as  large  as  before. 
The  patient  did  not  appear  to  be  benefited  by  the  operation. 
A  seton  had  been  passed  through  the  tumor  without  benefit, 
and  it  discharged  daily  a  large  quantity  of  fetid  fluid.  She 
became  chlorotic,  and  died  in  her  fifteenth  year. 

It  was  found  that  the  tumor  had  encroached  upon  the  caliber 
of  the  left  nostril,  and  compressed  the  antrum  of  that  side. 
Posteriorly,  it  had  forced  the  anterior  lobe  of  the  brain  into  the 
position  of  the  middle  lobe.  In  general,  the  inner  table  of  the 
skull  was  not  perforated.  The  tumor  was  found  to  contain 
numerous  cysts,  some  containing  reddish,  others  bluish,  or 
colorless  gluey  serum.  The  extended  bony  plate  was  of  similar 
consistence  to  that  of  the  skull  of  a  newly -born  hydrocephalic 
infant.  The  dimensions  of  the  swelling  were,  .5  inches  8  lines 
long,  4  inches  9  lines  broad,  and  4  inches  3  lines  high. 

Cystic  Tumor  of  the  Frontal  Sinus. —  {Arch.  Gen.,  Oct., 
Kov.,  Dec,  1870,  p.  539,  from  Etude  sur  les  tumeurs  de  la  glande 
lacrymale,  M.  Sautereau,  these.  Paris,  1870,  p.  68.)  Ilydro- 
pisie  du  sinus  frontal  du  cote  droit.  Ouverture  dans  I'orbite. 
Exophthalmos. 

M.  M -,  proprietaire  at  Avallon,  fet.  60  years.     Consulted 

Prof.  Pichet,  November,  1868,  concerning  a  tumor  which  had 
produced  an  exophthalmos  of  the  right  side.  For  mau}^  years 
he  had  been  subject  to  bleedings  from  the  nose.  When  these 
became  suppressed,  there  ensued  violent  headaches,  preventing 
sleep  and  throwing  the  patient  into  very  painful  nervous  crises. 
A  physician  administered  mercury  and  iodide  of  potassium, 
under  the  impression  that  tliere  was  cephalalgia  of  syphilitic 
orio;in,  but  without  securino;  the  least  assuao-ement. 

Sometimes,  in  addition  to  the  blood,  there  would  be  discharg- 
ed from  the  nose  serum,  and  a  material  resembling  pus.  For 
the  past  nine  months  there  had  not  been  any  nasal  discharge 
Apart  from  this  trouble,  the  patient  had  never  had  any  serious 
illness.     lie  was  otherwise  strong  and  well  nourished,  and  his 


TUMOES    OF    THE    FROISTTAL    SIISTUS.  329 

ocular  affection  did  not  appear  in  any  way  to  influence  his  good 
state  of  health. 

The  eye  of  the  right  side  was  strongly  depressed  downwards 
and  outwards,  so  that,  taking  a  horizontal  line,  the  right  cornea 
was  situated  two  centimetres  below  the  cornea  of  the  left  side. 
The  upper  eyelid  was  oidematous  and  elongated,  and  had  to  he 
raised  in  order  to  expose  the  eye.  For  more  than  a  month,  the 
patient  had  been  unable  to  distinguish  day  from  night  in  the 
affected  side.  The  conjunctiva  was  puffed  up,  forming  around 
the  cornea  a  most  notable  chemosis ;  the  pupil  was  dilated. 
This  permitted  an  examination  of  the  fundus  of  the  eye,  show- 
ing the  papilla  perfectly  healthy,  though  strongly  injected  and 
oedematous-like.  The  retina  and  choroid  were  in  a  normal  con- 
dition. The  eyeball  itself  did  not  appear  augmented  in  volume. 
That  which  pushed  it  downwards  and  outwards,  and  which 
elongated  the  upper  eyelid,  was  a  tumor  which  seemed  to  occu- 
py the  superciliary  fossa,  oblong  and  elongated,  like  the  eye- 
])row  under  which  it  was  situated,  and  which  appeared  to  have 
thrown  off  the  superciliary  ridge  several  millimetres  in  front 
of  that  of  the  opposite  side. 

This  tumor  was  hard  to  the  touch,  without  elevation  or  uneven- 
iiess  ;  but  on  introducing  the  finger  beneath  the  frontal  bone  so 
as  to  penetrate  the  orbital  ca^aty  between  the  plafond  of  the 
orbit  and  the  eyeball,  there  was  felt  at  its  middle  portion  a  pro- 
jection, perfectly  round,  with  a  large  base  placed  against  the 
plafond  of  the  orbit,  soft,  fluctuating,  and  to  a  certain  point  de- 
pressible.  On  compressing  it,  some  liquid  contents  passed  from 
under  the  touch,  which  resumed  their  position  as  soon  as  the 
compression  was  discontinued. 

The  patient  experienced  but  little  pain  during  these  various 
explorations,  and  there  was  noticed  a  slight  sensibility  of  the 
skin  of  the  brow,  determined  probably  by  the  compression  of  the 
frontal  nerves  ;  and  finally  a  complete  absence  of  the  shedding 
of  tears. 

In  consideration  of  these  various  particulars,  the  uniform  ten- 
derness of  the  superciliary  arcade,  the  fluctuating  tumefaction 
with  large  base  at  the  side  of  the  orbit,  the  abrupt  suspension  for 
six  months  of  the  alternative  mucous,  purulent,  and  sanguine- 


Sdi)  AFFECTIONS    OF    THE    FEONTAL    SINUS. 

lent  nasal  discharge,  M.  le  Prof.  Kicliet  considered  the  case  one 
of  those  known  as  hydropisie  of  the  frontal  sinus  with  irruption 
into  the  orbit,  and,  as  a  consequence,  progressive  exophthalmia 
downwards  and  outwards.  He  therefore  proposed  to  open  the 
tumor  at  its  fluctuating  point,  in  order  to  penetrate  the  frontal 
sinus,  and  establish  there  a  drainage  tube.  After  some  hesita- 
tion, the  operation  was  accepted,  and  practised  December  24th, 
1868,  in  the  following  manner : 

Immediately  below  the  eyebrow,  at  the  base  of  the  superior 
eyelid,  and  parallel  to  the  fold  of  this  membranous  veil,  an  in- 
cision was  made,  two  centimetres  in  length,  and,  after  having 
divided  the  entire  thickness  of  this  eyelid,  a  cyst  was  reached 
whose  membranous  walls  were  very  much  distended.  A  punc- 
ture was  made,  and  there  escaped  a  considerable  quantity  of 
a  thready  fluid,  viscous,  and  of  the  color  of  cafe  au  lait,  a  little 
dark.  The  opening  was  enlarged,  the  finger  carried  to  the  bot- 
tom of  the  sac,  which,  it  was  found,  extended  to  the  remotest 
portion  of  the  orbit.  The  bone  was  not  uncovered  in  any  por- 
tion of  its  extent ;  but  on  turning  the  pulpy  portion  of  the  fin- 
ger below  and  forward,  to  the  side  of  the  superciliary  ridge,  an 
opening  was  encountered,  through  which  a  canulated  sound  in- 
troduced through  it  manifestly  traversed  the  entire  cavity  of  the 
frontal  sinus.  A  gum  tube  perforated  with  lateral  openings 
was  introduced  and  maintained  in  the  opening ;  and  the  re- 
mainder of  the  sac  w^as  filled  with  fine  charpie  saturated  with  a 
solution  of  the  alcoholic  extract  of  walnut,  to  prevent  adhesive 
suppuration. 

The  next  day  and  the  days  following,  the  patient  was  remark- 
ably well,  and  did  not  appear  to  have  suffered  the  least  fatigue 
from  the  operation. 

Little  by  little,  the  quantity  of  charpie  introduced  into  the 
membranous  portion  of  the  cyst  was  diminished,  and  towards 
the  end  of  January  its  walls  were  completely  adherent  and 
there  remained  only  the  opening  which  gave  exit  to  the  tube 
of  caoutchouc. 

Little  by  little  the  eye  became  replaced  in  its  orbit,  the  upper 
eyelid  becoming  raised  again.  When  the  patient  left  Paris, 
early  in  March,  there  only  remained  a  little  fistulous  opening, 


TUMOES  OF  THE  FEONTAL  SIE'US.         331 

furnishing  every  day  a  few  drops  of  a  ropy  mnco-pns.  The  eye 
had  gradually  resumed  all  its  functions,  repassing  in  phases 
analogous  to  those  which  had  terminated  in  complete  abolition 
of  sight ;  that  is  to  say,  the  patient  had  corauienced  to  per- 
ceive light,  then  soon  distinguished  objects,  and  finally  could 
read  without  fatigue,  but  on  condition  of  closing  the  eye  of  the 
opposite  side.  In  fact,  when  he  wished  to  see  with  both  eyes, 
which  were  not  on  the  same  plane,  objects  appeared  double; 
but  the  diplopia  gradually  disappeared. 

Once  since  this  epoch,  the  opening  being  occluded,  the  pa- 
tient was  seized  with  violent  pains,  and  a  slight  degree  of  exor- 
bitism  was  produced. 

He  returned  to  Paris,  and  Prof.  Eichet  contented  himself 
with  forcing  in  a  sound,  which  gave  issue  to  a  little  liquid  pns 
which  had  accumulated,  sufficing  to  allay  the  suffering. 

In  case  of  the  reappearance  of  the  phenomena,  Prof.  Kiehet 
intends  to  perforate  the  osseous  septum  which  separates  the  cavi- 
ty of  the  nasal  f oss^  from  the  frontal  sinus,  by  means  of  a  curv- 
ed instrument  devised  for  the  purpose.  This  opening  will  per- 
mit the  liquid  to  run  directly  into  the  nose,  and  will  oppose  an 
obstacle  to  any  new  collection  in  the  cavity  of  the  sinus. 

Exostosis  of  Frontal  Shius^ — A  young  man,  set.  20,  of 
excellent  constitution,  entered  the  Hospital  Clinic  early  in 
July,  1869.  The  January  previous,  he  remarked  that  his  right 
eye  was  more  prominent  than  that  on  the  other  side,  l^ut  there 
was  no  suffering  or  pain  in  the  orbit.  For  three  months  there 
had  been  some  pain,  an  external  strabismus,  and  a  diplopia, 
which  continued  for  a  few  days  only.  There  was  an  abundant 
lachrymation.  There  was  nothing  particular  observed  at  the 
side  of  the  buccal  cavity,  or  the  nasal  fossse. 

At  his  entrance  he  presented  the  following  condition :  the 
eye  completely  out  of  its  orbit,  and  at  the  same  time  directed 
downwards  and  outwards.  The  ball  of  the  eye,  slightly  flattened 
from  before  backwards,  showed  some  alterations.  The  conjunc- 
tiva was  a  httle  red ;  it  was,  especially  internally,  infiltrated 
with  serosity,  as  by  a  slight  chemosis.     The  cornea  was  affected, 

'  Esophthalniie  consecutive  a  line  exostose  du  Sinus  Frontal.  Arch.  Gen. 
1870,  p.  541. 


332  AFFECTIOlSrS    OF   THE    FEONTAL    SINUS. 

some  small  ulcerations  being  seen  at  its  external  portion.  The 
anterior  cliamber  and  the  crystalline  lens  were  in  a  normal  con- 
dition. Ophthalmic  examination  showed  a  little  serons  effusion 
of  the  papillae,  the  veins  being  engorged  by  some  obstacle  to 
the  retnrn  of  the  circulation.  ISTevertheless,  vision  was  pre- 
served. The  inferior  eyelid  was  normal,  but  the  superior  one 
was  very  much  distended,  and  covered  the  superior  portion  of 
the  globe  of  the  eje.  At  the  superior  internal  angle  of  the 
orbit  there  was  a  marked  oedema.  By  palpation  there  was 
found  in  this  region  a  tumor  of  the  apparent  size  of  a  nut,  com- 
pletely immovable  and  very  adherent  to  the  inferior  face  of  the 
frontal  bone,  this  adherence  seeming  to  be  made  by  a  large  base. 
This  tumor,  covered  by  the  integuments  of  the  face,  appeared 
bosselated,  uneven,  and  of  an  eburnated  hardness.  Inwards  it 
extended  to  the  nasal  apophysis  of  the  superior  maxillary ; 
outwards,  to  the  internal  third  of  the  superciliary  ridge.  It 
was  impossible  to  limit  the  tumor  posteriorly.  A  small  steel 
needle  forced  into  the  integuments  could  not  be  penetrated  into 
the  tumor. 

In  view  of  all  these  signs.  Prof.  Richet  diagnosed  an  ebur- 
nated exostosis,  having  originated  in  the  frontal  sinus,  and  hav- 
ing develo]Ded  itself  at  the  superior  and  internal  portion  of  the 
orbitar  cavity. 

Prof.  Pichet  incised  the  integuments  at  the  superior  and  in- 
ternal portion  of  the  superciliary  ridge.  The  tumor  was  exposed, 
and  was  adherent  to  the  frontal  bone  by  a  large  base.  With 
the  aid  of  a  gouge  it  was  readily  enucleated,  and,  so  to  speak, 
peeled  h-orn.  its  surface  of  implantation. 

The  author  would  call  attention  to  a  very  valuable  and  elabo- 
rate article^  on  Affections  of  the  Frontal  Sinuses,  which  has  re- 
cently appeared  from  the  pen  of  Dr.  F.  Steiner,  one  of  the  as- 
sistants of  Prof.  Billroth,  of  Vienna.  It  came  under  the  author's 
notice  after  the  preceding  pages  were  wiitteu,  and  at  too  late  a 
date  for  incorporation  into  them. 

^  Ueber  die  Entwickelung  der  Stimhohlen  tind  deren  krankhafte  Erweiter- 
UBg  durch  Ansammking-  \-on  Fliissigkeiten.  Archiv  fiir  Klinische  Chirurgie. 
Bd.  xiii.  part  1,  1871,  p.  144. 


ACUTE    LARYIiTGITIS.  833 


CHAPTEE    XIV. 

AFFECTIONS    OF    THE    LARYISTX    AND    TRACHEA. 

ACUTE    LARYNGITIS.' 

Acute  laryngitis  is  an  inflammation  of  the  mucous  membrane 
of  the  larynx,  which,  for  the  most  part,  comes  on  suddenly,  is 
severe  in  character,  and  of  short  duration.  It  occurs  not  infre- 
quently as  an  idiopathic  affection,  the  result  of  sudden  or  unusual 
exposure  to  cold,  in  an  individual  subject  to  attacks  of  acute 
sore  throat ;  or  in  one  who  has  but  recently  become  convalescent 
from  some  disease  in  which  the  throat  had  been  affected,  such 
as  scarlatina,  measles,  etc.  Much  more  frequently  it  is  met 
with  in  the  cr)urse  of  the  chronic  laryngitis  attendant  upon  cer- 
tain forms  of  tu])erculosis  and  syphilis,  an  acute  laryngitis  from 
some  cause  or  other  becoming  superimposed  upon  the  chronic 
laryngitis  already  existing. 

The  most  frequent  direct  cause  of  acute  laryngitis  is  of  trau- 
matic origin,  such  as  the  involuntary  swallowing  of  boiling  water, 
or  caustic  solutions  ;  the  breathing  of  flame,  hot  vapors,  or  acrid 
substances  ; — the  inflammation  of  the  larynx  following  imme- 
diately. The  voluntary  deglutition  of  hot  or  caustic  substances 
with  suicidal  intent  is  not  apt  to  be  followed  by  acute  laryngitis. 

When  not  of  traumatic  origin,  acute  laryngitis  is  usually 
ushered  in  by  chilliness,  which  is  quickly  followed  by  fever ;  sore 
throat  being  complained  of  very  early.  There  is  severe  pain  in 
the  region  of  the  larynx,  with  tenderness  to  pressure  externally ; 
and  there  is  a  decided  sense  of  constriction,  as  though  from  a  for- 
eign body,  or  outside  pressure.  This  is  speedily  followed  by  dys- 
pnoea and  dysphagia.  The  voice  is  not  always  affected,  but  is  usu- 
ally hoarse,  dull  and  hollow  in  timbre,  though  occasionally  shrill 
and  piping,  and  it  is  emitted  with  some  difficulty,  and  often  only 
with  actual  paiu,  the  enunciation  of  a  sentence,  or  sometimes  even 
a  word,  being  interrupted  by  wheezing  and  prolonged  efforts  of 
inspiration,  symptoms  which  are  very  characteristic  of  constric- 


334        AFFECTIONS    OF    THE    LAETjSTX    AjSTD    TRACHEA. 

tion,  or  other  mechanical  impediment  above  the  glottis.  The 
respiration  will  be  sonorons,  sometimes  metallic.  The  cough  will 
be  hoarse,  deep,  hollow,  or  brazen,  like  that  of  croup.  As  the 
disease  progresses,  the  fever  becomes  more  intense,  the  local 
symptoms  increase  in  severity,  the  patient  exhibits  anxiety  as  to 
the  result,  suffocative  paroxysms  of  dyspnoea  ensue,  the  counte 
nance  becomes  cyanotic,  and,  unless  relief  is  procm-ed,  death 
soon  occurs  by  suffocation  and  coma. 

The  actual  amount  of  inflammatory  action  present  is  not 
usually  of  very  great  extent,  but  the  location  of  the  parts  in- 
volved is  such  that  a  moderate  amount  of  swelling,  insepa- 
rable from  the  action  of  inflammation  anywhere,  interferes 
seriously  with  the  integrity  of  the  respiratory  function  ;  and  it 
is  this  impediment  to  respiration,  mechanically  offered  by  the 
swollen  mucous  membrane  of  the  larynx,  that  constitutes  the 
grave  and  serious  lesion  in  this  disease. 

We  may  distinguish  two  forms  of  acute  laryngitis;  one  in 
which  the  inflammatory  action  is  confined  more  or  less  to  the 
mucous  membrane,  and  the  other  in  which  the  inflammation  in- 
volves the  sub-mucous  connective  tissue,  as  w^ell  as  the  mem- 
brane. This  latter  form  is  to  be  distinguished  from  the  inflam- 
mation of  the  same  tissue  which  occcurs  in  the  course  of  other 
complaints,  and  which  will  be  more  directly  treated  of  in  the 
section  following. 

In  the  one  form  of  laryngitis,  the  entire  laryngeal  mucous 
membrane  is  very  red  and  very  much  swollen.  The  epiglottis 
is  usually  erect,  and  its  mucous  membrane  is  swollen  out  to  two 
or  three  times  the  natural  bulk  of  the  organ.  In  like  manner 
there  will  be  a  similar  swelling  of  the  mucous  membrane  of 
the  aryteno-epiglottic  folds,  arytenoid  cartilages,  corpuscles  of 
Santorini,  and  ventricular  bands,  and  sometimes  even  of  that 
of  the  vocal  cords.  This  swelling  is  sometimes  so  great  as  to 
leave  but  a  very  small,  irregular  opening  free  for  the  passage  of 
air ;  and  it  will  impede  greatly  the  motion  of  the  parts,  so  that 
the  patient  will  not  be  able  to  dilate  his  glottis  to  its  full  extent. 

In  consequence  of  this  condition  of  things,  there  is  great 
danger  of  a  speedy  termination  of  the  patient's  life  by  suffoca- 
tion, before  there  has  been  time  enough  for  the  parts  to  pass 


ACUTE    LARYNGITIS.  335 

through  the  regular  course  of  inflammation  towards  resolution 
on  the  one  hand,  or  suppuration  on  the  other.  The  disease,  when 
not  fatal,  usually  continues  from  seven  to  ten  days.  I  have  oc- 
casionally seen  it,  however,  run  its  entire  course  in  from  twenty- 
four  to  forty-eight  hours ;  and  there  are  instances  recorded  in 
which  it  continued  for  from  twelve  to  twenty-four  hours  only. 

In  mild  cases  of  this  disease,  and  they  occur  more  frequently 
than  is  usually  known,  there  is  very  little  swelling  of  the  parts. 
The  entire  mucous  membrane  of  the  larynx  will  be  fiery  red, 
the  pain  severe,  the  cough  brassy,  the  voice  rough,  hoarse,  or 
piping,  but  there  will  be  no  impediment  to  respiration,  and  but 
little  to  deglutition,  and  this  more  from  the  pain  exercised  upon 
the  inflamed  structures  than  from  any  actual  obstacle  offered  on 
the  part  of  the  epiglottis  and  arytenoid  cartilages. 

In  the  second  foi'm  of  acute  laryngitis,  where  the  sub-mucous 
connective  tissue  participates  in  the  inflammatory  action,  in  part 
or  in  great  measure,  we  will  have  additional  swelling  to  that 
already  mentioned  above,  from  serous  infiltration  into  this  sub- 
mucous connective  tissue,  and  we  will  have  all  the  symptoms, 
and  recognize  the  appearances,  to  be  described  in  the  article  on 
oedema  of  the  larynx.  It  is  not  mere  violence  of  infiammation 
that  produces  this  form  of  the  affection,  for  in  some  instances  the 
acceleration  of  the  pulse,  heat  of  skin,  nervous  disturbance,  and 
other  phenomena  of  the  accompanying  febrile  excitement,  will 
be  much  less  than  in  the  form  of  laryiigitis  confined  to  the  mu- 
cous membrane.  On  the  other  hand  the  local  symptoms  will 
be  much  more  severe,  and  aj)peal  more  loudly  for  prompt  relief. 

In  the  treatment  of  acute  larjmgitis  it  is  essential  to  make  a 
pi'oper  diagnosis  at  an  early  date,  and  to  treat  it  promptly  and 
efiiciently,  bearing  in  mind  that  it  is  an  acute  disease,  rendered 
dangerous  not  from  the  violence  of  its  action,  but  on  account  of 
the  locality  which  is  invaded ;  and  that,  for  this  reason,  local 
treatment  takes  precedence  of  genei-al  treatment.  The  laryn- 
goscope is  here  of  the  greatest  service,  both  as  a  means  of  accu- 
rate diagnosis,  and  as  permitting  the  efiicient  application  of 
local  measures. 

The  systematic  treatment  of  inflammation  by  venesection — 
the  external  use  of  leeches,  the  internal  administration  of  reme- 


336       AFFECTIOlSrS    OF   THE    LAETNX   AND    TEACHEA. 

dies  acting  upon  the  various  emmictories— is  not  applicable  here 
as  in  inflammation  elsewhere,  because  we  dare  not  always  wait 
for  the  action  of  these  measures.  In  mild  cases,  the  external  ap- 
plication of  leeches,  the  use  of  salines,  and  the  iiihalation  of  the 
steam  of  warm  water,  or  of  astringent  solutions,  will  be  of  great 
benefit,  and  be  thoroughly  efficient,  with  perfect  rest,  quiet,  and 
silence.  In  severe  cases,  especially  where  there  is  oedema,  early 
scarification  of  the  parts,  by  the  method  to  be  described  in  a  later 
part  of  this  volume,  will  be  of  immense  service.  By  this  proce- 
dure the  parts  are  at  once  disgorged  of  their  blood ;  the  sei'um  is 
discharged  from  the  tumid  swellings ;  the  local  symptoms  are 
promptly  relieved,  and  respiration  is  rendered  efficient  for  the 
purposes  of  the  economy  in  her  own  efforts  at  cure.  It  is  rarely 
that  a  second  scarification  becomes  necessary. 

Where  scarification  is  inapplicable  from  want  of  appliances, 
want  of  practice,  or  other  causes,  the  trachea  should  be  promptly 
divided,  that  the  lungs  may  receive  a  due  supply  of  air  to  enable 
the  system  to  pass  through  the  natural  stages  of  the  inflamma- 
tory process.  This  operation  of  tracheotomy  must  not  be  delayed 
too  long,  but  should  be  performed  at  the  very  first  moment  that 
the  impediment  to  respiration  is  recognized  as  serious.  Delaj'ed 
too  long,  the  blood  will  have  become  so  poisoned  by  carboniza- 
tion that  the  relief  to  respiration  will  not  be  followed  by  efficient 
ox^^genation,  and  the  patient  will  succumb  a  few  hours  after 
having  been  relieved  of  the  local  symptoms.  This  is  the  his- 
tory of  many  cases  who  perished  after  tracheotomy,  because  it 
had  been  postponed  for  a  last  resort,  when,  if  resorted  to  early, 
the  probability  is  that  it  would  have  saved  life  in  at  least  some 
of  the  instances. 

In  the  acute  laryngitis  of  traumatic  origin  there  is  an  ele- 
ment of  complication  from  the  destruction  of  tissue  which  is 
produced  by  the  accident.  In  idiopathic  acute  laryngitis,  ulcer- 
ation is  rare,  and  is  usually  encountered  only  in  persons  whose 
health  has  been  seriously  impaired  by  previous  disease.  Another 
complication,  moreover,  in  traumatic  laryngitis  which  must  not 
be  lost  sight  of,  is  the  formation  of  abscesses  which  require  open- 
ing,— an  addition  to  the  treatment  already  described.    These  ab- 


(EDEMA    OF    THE    LAEYNX.  337 

scesses  usually  form  in  some  part  of  the  larynx  near  the  point 
of  injury  ;  but  they  may  occur  in  the  structures  adjacent  to  the 
larynx,  and  may  dip  down  the  sides  of  the  throat,  and  even 
penetrate  the  tissues  of  the  neck  so  as  to  present  externally. 

Disease  of  the  cartilages  is  not  frequent  in  acute  laryngitis. 
Occasionally  special  portions  of  the  larynx  are  the  seat  of  acute 
inflammation,  without  active  participation  of  the  adjacent  struc- 
tures. These  local  inflammatory  processes  have  been  termed 
epiglottitis,  chorditis  vocalis,  etc.,  to  designate  the  special  seat  of 
the  inflammation.  They  are  recognized  by  laryngoscopic  in- 
spection, and  are  to  be  treated  in  the  same  manner  as  acute 
laryngitis  of  a  mild  type  affecting  the  entire  organ.  If  great 
swelling  or  cedema  take  place,  scarification  will  be  demanded. 

Although  the  severe  symptoms  of  acute  laryngitis  continue 
for  a  few  days  only,  convalescence  is  occasionally  very  tardy, 
a  subacute  catarrhal  laryngitis  sometimes  lingering  behind  for 
weeks. 

(EDEMA    OF    THE    LARYNX. 

Under  certain  circumstances,  a  serous  or  sero-purulent  infil- 
tration takes  place  with  more  or  less  rapidity  into  the  submucous 
connective  tissue  of  the  upper  portions  of  the  larynx,  and  chief- 
ly upon  their  inner  surface.  The  result  is  first  to  impede  res- 
piration, and  subsequently  to  obstruct  it ;  and  if  the  condition 
does  not  soon  subside  spontaneously,  which  rarely  happens,  or  is 
not  promptly  relieved  by  surgical  interference,  the  patient  per- 
ishes in  a  period  varying  from  a  few  hours  to  a  few  clays. 

The  most  frequent  seat  of  the  affection  is  in  the  aryteno-epi- 
glottidean  folds  ;  and  both  of  them  are  usually  implicated. 
Sometimes  an  effusion  occupies  the  structures  of  the  epiglottis 
at  the  same  time,  and  sometimes  it  is  confined  to  the  epiglottis. 
Occasionally  it  implicates  the  lips  of  the  glottis,  converting 
them  into  thick  obstructing  pads,  but  the  infiltration  under 
these  circumstances  occurs  in  the  tissue  of  the  thyro-arytenoid 
muscle  itself,  rather  than  beneath  the  mucous  covering  of  the 
vocal  cord.  To  this  class  of  cases  alone  should  we  restrict  the 
term  oedema  of  the  glottis  : — a  term  unfortunately  too  generally 

employed  to  denote  every  other  oedema  of  the  laryngeal  struc- 

22 


338        AFFECTIOlSrS    OF   THE    LARYNX   AISTD    TRACHEA. 

tnres  also.  At  times  the  oedema  will  spare  the  upper  portions  of 
the  larynx,  and  be  confined  to  the  tissne  immediately  below 
the  vocal  cords,  and  under  such  circumstances  the  condition 
is  designated  as  sub-glottic  oedema  of  the  larynx  ;  a  form  of  the 
affection  to  which  attention  was  first  prominently  directed  by 
Dr.  Gibb/  who  narrates  several  instances,  and  enumerates  some 
pathological  specimens. 

Until  the  present  century  the  pathology  of  this  disease  was 
misunderstood.  Its  symptoms  were  usually  inferred  to  be  deno- 
tive  of  croup  in  the  adult ;  for  although  the  affection  has  been 
known  to  attack  the  infant  at  the  breast,  and  even,  in  one  re- 
ported instance,  a  new-born  babe ;  and,  on  the  other  hand,  to 
make  its  appearance  in  extreme  old  age  (a  case  being  report- 
ed as  occurring  at  81),  it  is  usually  encountered  in  early  and 
middle  adult  life. 

The  illustrious  Washington  perished  in  1799  by  this  affection, 
after  an  illness  of  but  little  more  than  twenty-four  hours.  Por- 
ter ^  mentions  that  one  of  the  physicians  who  lost  his  life  by  it 
in  1808,  declared  that  his  disease  was  to  be  considered  as  croup. 
It  was  in  this  same  year,  1808,  that  M.  G.  L.  Bayle  communi- 
cated his  famous  paper  on  oedematous  laryngeal  angina  to  the 
Society  of  the  Parisian  School  of  Medicine ;  pre^dous  to  which 
time,  however,  Morgagni,  in  his  letter  on  serous  apoplexy,  and 
afterwards  Bichat,  had  described  the  post-mortem  appearances 
of  infiltration  of  the  aryteno-epi glottic  folds,  which  had  not 
been  detected  before  death  ;  and  at  a  still  earlier  period  symp- 
toms of  a  disease  which  must  have  been  the  same  thing,  had 
been  recorded  without  any  evidence  of  a  knowledge  of  the  pe- 
culiar lesion  which  had  given  rise  to  them. 

Oedema  of  the  larynx  sometimes  occurs  in  the  progress  of 
ordinary  acute  laryngitis,  and  constitutes  the  chief  source  of 
immediate  danger  in  that  complaint.  It  is  also  often  present 
in  the  traumatic  laryngitis  caused  by  the  accideutal  deglutition 


'  On  Diseases  of  the  Throat  and  Windpipe.  2d  edition,  London,  1864,  p.  211 
et  seq. 

^  Observations  on  the  Surgical  Pathology  of  the  Larynx  and  Trachea.  Lon- 
don, 1837,  p.  79. 


(EDEMA    OF    THE    LARYNX.  339 

of  hot  liquids  or  caustic  solutions,  but  is  not  produced  wlien 
they  are  voluntarily  swallowed  in  suicidal  intent. 

"Wlien  idiopathic,  it  is  more  frequent  in  men  than  in  women, 
and  in  free-livers  than  in  persons  of  more  temperate  habits. 

It  also  occurs  sometimes  in  the  course  of  pharyngitis,  what- 
ever may  have  been  its  origin ;  occasioually,  too,  in  the  stridu- 
lous  laryngitis  of  children. 

It  sometimes  makes  its  appearance  suddenly  during  the 
course  of  other  maladies,  and  is  not  confined  to  such  as  are 
ordinarily  accompanied  by  affections  of  the  throat.'  It  is  most 
apt  to  occur  in  the  waning  stages  of  disease,  in  the  stage  of  con- 
valescence, or  defervescence  rather,  probably  from  want  of  due 
care  as  to  protection  from  exposure  to  currents  of  air.  Thus 
it  has  been  encountered  in  scarlatina,  measles,  smallpox,  erysipe- 
las, typhus  fever,  t^qohoid  fever,"  Bright's  disease  of  the  kidney, 
whooping-cough,  pulmonary  catarrh,  pneumonia,  and  in  diseases 
of  organs  productive  of  anasarca. 

It  is  sometimes  produced  in  the  course  of  chronic  laryngitis 
of  tuberculous  and  syphilitic  origin  ;  in  the  pharyngitis  accom- 
panying malignant  disease  of  the  tongue,  pharynx,  and  CESopha- 
gus,  whether  directly  implicating  the  larynx  or  not ;  in  glandular 
and  other  tumors  in  the  cervical  region  ;  in  aneurism  of  the  arch 
of  the  aorta  ;  and  in  cases  of  wounds  and  other  mechanical  inju- 
ries of  the  throat  and  parts  adjacent.  It  also  occurs  in  connec- 
tion with  the  sore  throat  of  smallpox,  and  may  prove  fatal. 

Although  occurring  in  persons  in  good  general  health,  it  is 
more  apt  to  make  its  appearance  in  those  of  broken-down  con- 
stitutions, or  recently  convalescent  from  acute  disease  ;  and  in 
most  instances  there  would  appear  to  be  some  peculiar  predis- 
position, the  nature  of  which  is  not  understood  ;  for  there  are  in- 

^  Dr.  Farre  records  a  case  suddenly  supervening  in  a  case  of  jaundice  from 
obstruction  of  the  hepatic  duct. — Lancet,  April  21,  1860,  p.  393. 

Dr.  W.  Moore  records  the  case  of  a  medical  gentleman  suffering  under  abr 
dominal  aneurism,  in  whom  temporary  and  recurrent  aphonia  was  found  by 
Dr.  Smyley  to  be  due  to  oedema  of  the  vocal  cords. — Dub.  Quart.  Jour..,  Aug. , 
1869,  p.  13. 

'^  In  this  connection,  a  valuable  paper  from  the  pen  of  Dr.  Emmet  can  be 
consulted  with  advantage. — Am.  Jour.  Mtd.  Sci.,  July,  1856. 


340        AFFECTIONS    OF    THE    LAEYNX    AND    TKACHEA. 

stances  on  record  of  more  than  one  attack  in  the  same  indi- 
viduaL 

Under  all  ch'cnmstances,  the  immediate  exciting  cause  seems 
to  be  exposure  to  cold  and  moisture. 

The  symptoms  are  marked,  and  in  most  cases  come  on  more 
or  less  suddenly,  and  increase  in  severity  with  great  rapidity. 
There  is  usually  more  or  less  tenderness,  which  only  in  some 
cases  amounts  to  actual  pain,  with  a  sense  of  constriction  in  the 
throat  as  from  the  presence  of  a  foreign  body  there  ;  difficulty 
of  inspiration  sometimes  accompanied  by  a  whistling  or  stridu- 
lous  sound,  and  increasing,  as  the  disease  progresses,  to  all  the 
phenomena  of  impending  suffocation ;  cough  to  a  greater  or  less 
degree,  which  is  often  ineffective ;  feebleness,  hoarseness,  or 
extinction  of  voice ;  more  or  less  dysphagia,  which  sometimes 
amounts  to  comj)lete  inability  to  swallow,  in  some  instances  of 
which  the  attempt  to  swallow  has  been  immediately  productive 
of  a  fatal  issue. 

Inspection  of  the  throat  usually  reveals  more  or  less  inflamma- 
tion of  the  structures  under  sight,  and  sometimes  infiltration  of  the 
palate,  uvula,  tonsils,  and  occasionally  even  of  the  pharynx  ;  but 
very  often  no  evidence  of  the  disease  is  apparent  in  the  throat. 
The  infiltration  of  these  parts  is  most  apt  to  occur  in  oedema, 
the  result  of  acute  inflammation. 

Laryngoscopic  inspection,  where  possible,  and  it  is  usually 
practicable  in  skilful  hands,  reveals  the  nature  of  the  lesion  at 
once.  Exploration  with  the  finger  is  almost  always  applicable, 
and  permits  the  detection  of  the  swollen  structures,  as  far  as  re- 
gards the  implication  of  the  epiglottis  and  the  aryteno-epiglottic 
folds.  Care  must  be  taken  in  this  digital  examination,  on  ac- 
count of  the  liability  to  suffocation.  Prof.  Trousseau  mentions'  a 
ease  in  which  he  induced  in  this  way  a  suffocative  paroxysm 
which  he  was  afraid  would  prove  fatal. 

When  the  epiglottis  is  involved,  it  can  very  often  be  perceived 
on  pressing  down  the  tongue,  and  usually  appears  as  a  bladder-like 
eminence  projecting  above  the  base  of  that  organ,  varying  in 
size  from  that  of  a  peanut,  which  it  not  unfrequently  resembles 

^  Clinical  Medicine.     Translation,  vol.  iii.,  p.  98. 


(EDEMA    OF    THE    LARYNX.  341 

in  shape,  to  tliat  of  the  bulk  of  a  wahmt ;  and  it  is  occasionally, 
as  in  two  or  three  cases  seen  by  the  wi'iter,  constricted  in  its 
central  portion  by  the  glotto-epiglottic  ligament,  giving  the  ap- 
jDcarance  of  two  bladders  instead  of  one.  Occasionally  the 
swollen  aryteno-epiglottic  folds  can  be  brought  in  sight  by  titil- 
lating the  base  of  the  tongue  so  as  to  produce  an  effort  of  retch- 
ing, which  raises  the  entire  larynx  ;  but  when  the  epiglottis  is 
swollen  they  are  less  apt  to  be  brought  in  sight. 

Yiewed  in  the  laryngoscopic  image,  the  appearances  of  oedema 
of  the  larynx  are  very  characteristic.  A  pale  reddish,  or  some- 
times yellowish  translucent  swelling,  irregularlj^  globular  or  oval 
in  outline,  in  general  appearance  not  unlike  that  of  an  oedema- 
tous  prepuce,  or  osdematous  eyelid,  is  found  occupying  the  ary- 
teno-epiglottic folds,  usually  both  of  them,  though  not  always  in 
equal  extent,  and  sometimes  occupying  one  side  only.  These 
swellings  project  towards  each  other,  narrowing  the  laryngeal 
entrance  into  a  mere  slit,  which  becomes  smaller  during  inspira- 
tion from  the  pressure  of  the  air  upon  the  swellings,  so  that 
sometimes  the  surfaces  adhere,  slightly  pressing  them  together, 
while  during  the  passage  of  the  expiratory  current  they  are  more 
or  less  separated,  and  sometimes  permit  a  view  of  the  parts  below. 
Usually  all  distinct  appearance  of  false  vocal  cord  is  oblitera- 
ted, the  entire  mass,  ary-epiglottic  fold  and  ventricular  band 
appearing  as  one  structure.  The  parts  do  not  present  a  very 
vascular  aspect,  and  are  sometimes  more  or  less  covered  with 
masses  of  mucus.  When  the  epiglottis  is  affected,  it  is  seen  as 
a  huge  mucous  bag  of  limpid  fluid  overhanging  the  laryngeal 
entrance,  and  often  preventing  a  view  of  the  interior.  Some- 
times the  laryngeal  face  is  not  implicated,  but  the  lino-ual 
surface  and  crest  is  almost  always  affected.  When  the  disease 
does  not  occupy  the  upper  portions  of  the  larynx,  the  lower 
portions  are  seen  to  project  laterally  as  osdematous  swell- 
ings. 

.  This  affection  is  of  a  very  serions  nature,  on  account  of  the 
liability  to  suffocation.  This  has  been  known  to  occur  at  the 
very  iirst  attack,  before  there  had  been  any  opportunity  of 
establishino;  a  diao-nosis.     Hence  it  is  essential  to  be  able  to  re- 


342        AFFECTIONS    OF    THE    LAKYNX   AND    TRACHEA.  ' 

cognize  the  condition  promptly,  and  to  treat  it  efficiently,  for 
temporizing  treatment  may  sacrifice  a  patient  who  ought  to 
have  been  saved.  Usnally,  however,  the  paroxysms  subside 
spontaneously,  leaving  intervals  of  impeded  respiration.  This 
is  at  first  confined  chiefly  to  inspiration,  on  account  of  the  pres- 
sure inwards  of  the  tumid  folds  of  membrane  by  the  atmos- 
pheric current ;  but,  if  the  disease  23rogresses,  expiration  will 
be  impeded  also. 

"Where  the  oedema  is  dependent  on  acute  disease,  the  parox- 
ysms will  be  abrupt,  violent,  and  occur  irregularly  at  intervals 
of  a  few  hours.  AVlien  the  result  of  chronic  disease,  the  dys- 
pnoea gradually  increases  until  it  culminates  in  a  paroxysm  of 
suffocation,  which  passes  off  with  more  or  less  relief  to  the 
dyspnoea,  to  recur,  as  the  disease  progresses,  in  the  course  of  a 
few  days,  or  perhaps  a  few  weeks.  Finally,  however,  these  inter- 
vals become  shorter,  until  several  paroxysms  occur  within  the 
twenty-four  hours,  being  as  a  rule  more  violent  at  night  than  in 
the  daytime. 

In  sub-glottic  oedema  the  breathing  is  still  more  stridulous, 
much  like  that  of  laryngismus  stridulus  ;  but  certainty  of  diag- 
nosis can  be  secured  only  by  laryngoscopic  examination,  when 
the  projecting  pads  of  tumid  mucous  membrane  are  seen  be- 
neath the  vocal  cords,  and  encroaching  on  the  caliber  of  the 
larynx.  There  is  usually  a  more  copious  secretion  of  mucus 
than  in  supra-glottic  oedema,  where  there  is  sometimes  hardly 
any,  and  this  mucus  contains  more  or  less  fibrin.  In  some  of 
the  cases  recorded  by  Dr.  Gibb,  the  contents  of  the  oedematous 
tumors  were  essentially  fibrinous,  and  simulating  new  growths. 

The  best  treatment  for  this  condition  is  efficient  scarification 
of  the  tumid  swelling.  This  gives  egress  to  the  pent-up  fluids, 
and  usually  arrests  the  threatening  symptoms  at  once.  This 
may  readily  be  done  with  a  long  curved  bistoury,  protected  to 
within  a  line  or  two  of  its  point,  and  directed  to  the  parts  by 
the  guidance  of  the  flnger  upon  the  swelling,  or  upon  the 
epiglottis.     Prof.  Buck,  of  New  York,  has  devised '  an  excel- 

'  (Edematoiis  Laryngitis,  etc.,  Trans.  Am.  Med.  Ass'/i.,  Yol.  i.  p.  135  et 
seq.  ;   illustrated. 


(EDEMA    OF    THE    LAEYISTX.  343 

lent  knife  for  this  purpose  (Fig.  62),  which,  if  at  hand,  is  to 
be  preferred  to  the  bistoury.  When  the  laryngoscope  is  em- 
ployed, the  laryngeal  knife  offers  a  more  secure  method  of  ope- 


Buck's  knife  for  scarifying  an  (Edematous  larynx. 

rating,  and  with  less  danger  of  wounding  parts  that  should  not 
be  cut  into.  The  spasm  produced  is  usually  insignificant.  There 
is  not  a  great  deal  of  bleeding  as  a  rule,  a  drachm  or  two  perhaps, 
and  sometimes  hardly  any  ;  but  occasionally,  as  has  happened 
in  the  ^vriter's  experience,  the  bleeding  has  been  profuse,  re- 
quiring the  most  assiduous  efforts  on  the  part  of  the  patient  to 
expectorate  the  blood  flowing  down  the  larynx,  so  that,  despite 
the  relief  to  the  general  dyspnoea,  the  patient  has  had  to  cough 
for  his  life  ;  and  in  one  instance,  where  oedema  of  the  aryteno- 
epiglottic  folds  had  ensued  suddenly  during  a  laryngitis  of 
syphilitic  origin,  it  required  the  external  and  internal  appli- 
cation of  ice  for  many  minutes  to  restrain  a  bleeding  of.  really 
alarming  character  ;  so  that  tracheotomy  was  determined  upon 
in  case  of  a  return  of  the  edematous  condition,  which  fortunate- 
ly did  not  take  place.  Where  the  bleeding  is  but  slight,  it 
should  be  encouraged  by  warm  water  or  the  inhalation  of 
steam.  Scarification  of  the  external  portion  of  the  folds,  or 
their  external  edges,  is  not  liable  to  this  objection  of  excessive 
hemorrhage,  and  has  been  resorted  to  by  the  writer  in  two  or 
three  instances  occurring  more  recently,  and  with  satisfactory 
success.  After  the  scarification,  the  parts  present  a  wrinkled 
appearance,  with  bloody  marks  of  the  incisions,  as  examined 
with  the  laryngoscope. 

In  cases  of  acute  oedema,  a  second  scarification  is  rarely  re- 
quisite, especially  when  the  progress  of  the  affection  can  be 
watched  with  the  laryngoscope  ;  but  where  the  oedema  occurs 
in  the  progress  of  chronic  affections  of  the  larynx,  the  opera- 
tion may  be  required  again  and  again. 

Where  the  symptoms  are  very  urgent,  that  is  to  say,  where 
death  is  imminent  at  the  moment,  the  proper  procedure  would 
appear  to  consist  in  opening  the  trachea  without  delay. 


344        AFFECTIONS    OF    THE    LARYNX    AND    TRACHEA. 

This  does  not  alwaj'S  succeed  in  rescuing  the  patient.  Two 
cases  of  this  kind,  followed  by  fatal  results,  are  recorded  by 
Drs.  Pitman  and  Page/ 

The  trachea  is  to  be  opened  in  preference  to  the  laiynx,  in 
consequence  of  its  greater  distance  from  the  seat  of  the 
disease,  and  the  lesser  liability  to  protraction  of  tlie  complaint, 
as  well  as  for  the  reason  that  the  disease  may  be  extending 
low  down  in  the  larynx,  and  therefore  exist  at  the  very  seat 
selected  for  an  opening  into  the  larynx.  Life  being  thus 
saved,  scarification  of  the  oedematous  structure  may  be  pur- 
sued with  more  deliberation.  Under  circumstances  of  great 
urgency,  an  opening  must  be  made  below  into  the  trachea  with 
the  pocket-knife,  if  no  surgical  instrument  is  at  hand,  and  with- 
out any  dissection,  the  delay  for  which  may  result  in  the  loss  of 
the  patient.  The  case  is  so  desperate  as  to  be  rescued  only  by 
desperate  means. 

Prof.  Stromeyer  recommends  bursting  the  bladder-like  swell- 
ing by  a  smart  stroke  of  the  finger  at  the  moment  of  examina- 
tion. The  epiglottis,  when  involved,  may  thus  be  firmly  pressed 
against  the  root  of  the  tongue,  and  would  be  very  apt  to  suffer 
rupture  of  its  mucous  membrane  under  a  powerful  stroke  from 
the  finger.  Where  this  can  be  done  it  would  appear  to  be  more 
desirable  than  scarification,  at  least  in  the  first  instance. 

Where  pressure  or  scarification  fails  to  give  immediate  relief, 
tracheotomy  should  be  resorted  to  at  once,  for  the  disease 
threatens  death  by  suffocation  before  any  impression  can  be 
made  by  ordinary  antiphlogistic  remedies  ;  although  it  is  due  to 
it  to  say,  that  cases  have  recovered  under  general  antiphlogistic 
treatment ;  °  and  one,  in  particular,  reported  by  Dr.  Eoberts,^  is 
interesting  from  the  fact,  that  the  subject  died  in  a  subsequent 
attack  fourteen  years  afterwards.  Frequent  pressure  of  the 
parts,  with  a  view  to  absorption,  is  hardly  worthy  of  mention 
as  a  method  of  treatment ;  and  catheterism  of  the  larynx,  more 
lionored   in  this   connection   by  breach   than   by   observance. 

1  Lancet,  April  21,  1860,  p.  393. 

'Tide  Med.-Ckir.  Trans.     Vol.  v.,  p.  156,  Mr.  Wilson.    Ibid.  vol.  ix.,  p.  31, 
D  r.  Arnold     Edinh.  Med  and  Surg.  Jour. ,  vol.  x. ,  p.  284,  Mr.  Anderson. 
^  Med.-Chirurg.  Trans.,  vol.  vi.,  p.  135. 


(EDEMA    OF   THE    LAETISTX.  345 

Prof.  Trousseau'  has  recorded  a  severe  case  of  oedema  of  the 
epiglottis  and  ary-epiglottic  folds,  which  was  promptly  relieved 
by  inhalations  of  tannin ;  and  a  couple  of  instances  in  which 
narcotic  inhalations  had  a  very  happy  effect  have  been  related 
elsewhere  by  the  writer/  But  treatment  by  inhalation  must 
be  very  rarely  applicable,  and  not  at  all  so  where  the  symptoms 
are  urgent.  In  one  of  the  author's  cases  referred  to,  it  was  not 
employed  with  the  hope  of  a  favorable  result,  but  as  a  means  of 
temporary  alleviation  while  in  quest  of  an  instrument  for  scari- 
fication. 

Sub-glottic  cfidema  demands  the  performance  of  tracheotomy, 
if  the  effusion  cannot  be  promptly  subdued  by  the  use  of  constitu- 
tional measures,  and  the  inhalation  of  steam,  astringent  sprays, 
etc. ;  scarification  being,  on  account  of  the  situation  of  the 
infiltration,  almost  always  impracticable.  If  delayed  too  long 
in  this  form,  even  tracheotomy  may  be  impotent  to  save  the 
patient,  an  unfortunate  case  of  which  kind  occurred  a  few 
years  ago  in  the  author's  practice. 

The  oedema  which  occurs  during  the  progress  of  chronic 
laryngeal  disease  usually  comes  on  gradually,  rarely  insidiously, 
and  may  continue  for  several  weeks  and  even  months  without 
producing  any  suffocative  symptoms ;  and  this  even  when  the 
entrance  into  the  larynx  is  very  much  obstructed  by  the  swell- 
ing. It  seems  as  if  the  system  gradually  accustomed  itself  to  a 
narrowing  of  the  air-passages  on  the  one  hand,  while  on  the 
other,  the  general  ill-health  of  the  patient  and  the  lack  of  active 
exercise  seems  to  make  less  demand  for  a  large  supply  of  atmos- 
pheric air.  Certain  it  is  that  an  amount  of  oedema  is  tolerated  in 
chronic  affections  of  the  larynx,  which  would  produce  symptoms 
of  intense  dyspnoea  if  it  occurred  suddenly. 

The  laryngoscope  furnishes  the  only  certain  means  of  diag- 
nosis in  these  cases. 

The  oedema  is  more  apt  to  be  confined  to  one  side  than  in  the 
acute  variety,  probably  because  the  laryngeal  affection  is  one- 
sided. 

1  Clinique  Medicale  de  I'Hotel-Dieu.     Paris,  1861,  p.  475. 

'•'  Inhalation;  its  Therapeutics  and  Practice.     PhUad.,  1867,  p.  138. 


346        AFFECTION^S    OF   THE    LAEYJSTX    AND    TRACHEA. 

Ill  these  cases  the  condition  is  often  due  to  disease  of  tlie  laryn- 
geal cartilages  which  have  become  carious ;  and  the  necrosed 
cartilages  are  productive  of  laryngeal  abscesses  on  their  way  to 
the  exterioi", — here,  the  interior  of  the  tube ;  and  sero-purulent 
secretion  will  take  place  in  the  adjacent  submucous  connective 
tissue,  producing  the  phenomena  of  laryngeal  oedema.  The  cri- 
coid cartilage  and  the  arytenoids  are  the  most  prone  to  become 
diseased  in  this  manner ;  but  the  other  cartilages  possess  no  im- 
munity. kSometimes  the  detached  portions  of  dead  cartilage 
are  expectorated  in  coughing,  and  there  is  rapid  abatement  in 
the  urgency  of  the  dyspnoeatic  symptoms ;  but  without  any  real 
progress  towards  cure  of  the  disease.  It  is  only  occasionally 
that  the  sequester  can  he  seen  by  means  of  the  laryngoscope, 
and  detached  with  forceps ;  and  if  any  difiiculty  in  detachment 
presents  itself,  tracheotomy  may  be  necessary,  if  the  integrity 
of  the  caliber  of  the  tube  is  threatened. 

Opening  the  trachea  for  the  purpose  of  setting  the  larynx  at 
rest  in  chronic  affections,^  as  was  formerly  advised  in  certain 
quarters,  is  not  justifiable;  for  the  affection  terminates  in 
death,  and  the  respite  is  hardly  worth  its  cost.  Scarifications, 
followed  by  the  local  application  of  astringent  solutions,  includ- 
ing, as  such,  solutions  of  nitrate  of  silver,  chloride  of  gold, 
chloride  of  zinc,  and  the  like,  with  emollient  and  narcotic 
inhalations,  constitutes  perhaps  the  best  treatment.  Blisters 
and  other  external  counter-irritants  rarely  do  good,  and  are 
often  productive  of  injury. 

In  illustration  of  the  immense  value  of  the  laryngoscope  in 
determining  the  exact  condition  of  parts  in  oedema  of  the 
larynx,  and  thus  watching  the  effects  of  remedies,  the  two  cases 
following,  from  several  recorded  in  the  author's  note-books, 
may  be  instanced,  in  which  the  prompt  institution  of  local 
antiphlogistic  measures  controlled  the  progress  of  the  disease, 
which,  under  other  circumstances,  would  probably  have  in- 
creased in  severity,  and  perhaps  have  demanded  the  perform- 
ance of  tracheotomy,  or,  at  least,  of  scarification. 

'  Porter,  "On  the  Larynx  and  Trachea,"  p.  118,  states  that  several  cases 
have  been  published  strongly  exemplifytag  the  value  of  this  practice  vrith  the 
view  of  placing  the  larynx  in  that  state  of  quiescence  so  necessary  to  the 
healing  of  a  sore  anywhere. 


CHKOlSriC    LAEYJSTGITIS.  347 

CEdema  Laryngis. — Mrs.  E.  S ■  applied  at  9  p.m.  on  tlie 

night  of  April  14, 1866,  on  account  of  great  oppression  in  breath- 
ing, which  had  gradually  supervened  on  exposure  to  cold  some 
forty-eight  hours  previously.  The  palate  and  arches  were  in- 
flamed, as  was  also  the  larynx,  and  both  ary-epiglottic  folds  were 
in  a  marked  state  of  oedema.  The  symptoms  were  severe,  but  not 
urgent.  Pure  sulphuric  ether  was  projected  upon  the  parts  by 
means  of  the  hand-ball  spray  producer,  and  the  patient  was  then 
made  to  inhale  from  Siegle's  steam-nebulizing  apparatus  an  ounce 
of  a  saturated  solution  of  chlorate  of  potassa.  On  the  following 
day  she  was,  to  all  intents  and  purposes,  relieved  from  her  dis- 
tressing symptoms.  There  was  still  a  little  hoarseness,  but  there 
was  no  longer  any  obstruction  to  respiration.  The  larynx  was 
still  congested,  but  the  oedematous  condition  of  the  folds  had  al- 
most completely  subsided.  A  douche  of  sulphate  of  zinc,  fifteen 
grains  to  the  ounce  of  water,  was  propelled  upon  the  parts  sev- 
eral times,  which  completed  the  treatment  in  a  satisfactory  man- 
ner. 

CEdema  Laryngis   cured  "by  Alum-Water. — Mrs.  F -, 


ajt.  40,  applied  to  me  June  1st,  1866,  with  oedematous  infiltration 
of  both  arytenoid  cartilages  and  ary-epiglottic  folds.  Frequent 
inhalations  of  the  spray  of  strong  alum-water  promoted  the  re- 
sorption of  the  effusion  in  forty-eight  hours.  A  year  or  two 
afterwards,  this  patient  applied  again,  with  anosdema  which  had 
progressed  as  far  as  on  the  previous  occasion,  and  it  was  promptly 
subdued  by  the  same  means. 


CHEONIC   LAKYNGITIS. 


Chronic  inflammation  of  the  larynx  is  apt  to  occur  during 
the  progress  of  chronic  pulmonary  phthisis  ;  as  one  of  the  later 
manifestations  of  syphilis  ;  as  an  accompaniment  of  carcinoma- 
tous disease  ;  as  the  result  of  long-continued  irritation  from  mi- 
nute particles  of  extraneous  matter  inhaled  by  accident,  or  in 
the  course  of  special  employments ;  as  an  extension  of  bron- 
chitis and  tracheitis  ;  as  the  result  of  frequent  attacks  of  catar- 
rhal laryngitis  ;  and,  very  rarely,  as  a  sequel  to  acute  larjaigitis. 

Sometimes  an  apparently  idiopathic  case  of  chronic  laryugi- 


348      AFFEcnoisrs  of  the  larynx  and  trachea. 

tis  is  encountered,  without  being  referable  to  any  particular 
cause  of  initial  disturbance. 

Chronic  laryngitis,  however  produced,  is  liable  to  terminate  in 
ulceration  of  the  mucous  membrane,  producing  the  condition 
designated  as  ulcerative  chronic  laryngitis.  In  some  respects 
these  forms  of  the  disease  varj-,  but  in  very  many  they  are  alike, 
as  to  the  seat  and  appearance  of  the  ulcerations. 

The  chronic  laryngitis  without  apparent  cause,  which,  for 
convenience,  may  be  styled  idiopathic,  is  the  least  liable  to  take 
on  ulcerative  action. 

In  most  instances,  the  trachea  participates  in  the  inflamma- 
tion more  or  less  extensively  ;  and  in  some  there  is  also  an  in- 
active inflammatory  condition  of  the  pharjmgeal  and  nasal  mu- 
cous membranes,  which  is  sometimes  antecedent  to  the  laryngeal 
affection,  and  sometimes  subsequent  to  it. 

As  seen  with  the  laryngoscope,  the  mucous  membrane  of  the 
parts  involved  is  always  more  or  less  congested,  and  the  color 
varies  from  a  mere  deepening  of  the  normal-jjink  or  red,  to  a 
deep-red,  brownish-red,  and  in  some  cases  a  purplish-red.  En- 
larged superficial  veins  are  sometimes  seen  coursing  upon  the 
surface,  very  often  confined  to  the  epiglottis,  though  sometimes 
observed  upon  the  ary-epiglottic  folds,  and  occasionally  on  the 
vocal  cords  themselves. 

Very  often  the  membrane  has  also  a  velvety  appearance,  and 
looks  as  if  it  were  thickened  or  indurated.  The  vocal  cords  do 
not  always  participate  in  the  general  condition ;  theii'  color 
often  appearing  even  whiter  than  natural  by  the  contrast.  They 
are  usually  involved,  however,  and  then  they  will  be  of  a  pink- 
color,  from  which  they  may  var}^  to  a  red  as  intense  as  that  of 
the  other  portions  of  the  larynx.  The  cartilages  of  Santorini 
are  very  apt  to  be  unusually  prominent,  with  clubbed  globular 
outline,  and  very  red  in  color ;  and  if  there  be  any  deposit  of 
mucus  it  is  apt  to  be  seen  in  the  inter- arytenoid  fold  of  membrane 
at  their  base.  Clumps  of  mucus  sometimes  collect  upon  the 
ventricular  bands,  and  also  adhere  to  the  vocal  cords,  stretching 
often  in  viscid  strands  from  one  side  to  the  other.  The  vocal 
cords  are  very  apt  to  be  thickened  at  their  edges,  even  when  not 
much  changed  in  color.     In  some  instances,  the  entire  interior 


CHRONIC    LAEYNGITIS.  349 

of  the  larynx  is  bathed  in  a  glairy  mucus.  The  epiglottis  is 
very  likely  to  show  some  erosion  upon  its  edge,  even  when  no 
similar  appearance  can  be  detected  elsewhere.  When  the  tra- 
chea is  involved,  the  membrane  covering  the  rings  is  reddened, 
and  the  color  of  the  intermediate  portions  deepened  into  a  darker 
red. 

In  severe  cases  the  mucous  membrane  is  ulcerated,  and  usual- 
ly in  several  places;  most  frequently  perhaps  upon  the  posterior 
laryngeal  wall,  the  ary-epiglottic  folds,  and  upon  the  posterior 
portions  of  the  vocal  cords  ;  and  upon  these  localities  we  some- 
times discover  small  irregular  papillary  excrescences,  usually 
proliferations  of  pavement  e23ithelium  ;  sometimes  of  connective 
tissue  elements. 

The  epiglottis  is  often  thickened,  sometimes  to  four  or  five 
times  its  normal  dimension ;  sometimes  it  appears  to  be  softened 
and  flaccid,  and  not  unfrequently  has  undergone  some  altera- 
tion in  shape,  with  loss  of  symmetry.  In  other  cases  it  is  nodu- 
lated and  spongy  in  appearance.  After  a  certain  length  of 
time,  mo]"e  or  less  ulceration  occurs  in  various  parts  of  the  mu- 
cous membrane,  but  chiefly  in  tuberculous  and  syphilitic  cases. 

There  are  no  specific  appearances  distinguishing  syphilitic 
ulceration  from  that  occurring  in  tuberculosis.  The  edges  of 
the  ulcer,  in  syphilis,  are  perhaps  more  frequently  sharp  in  out- 
line, the  surrounding  tissue  redder  in  color,  and  the  superficies 
of  the  ulcer  less  regular  in  appearance.  The  additional  ele- 
ments of  each  case  must  be  duly  considered  to  arrive  at  a  dif- 
ferential diagnosis.  Ulcerations  not  unfrequently  invade  the 
epiglottis  at  its  base,  or  are  studded  irregularly  along  its  laryn- 
geal face,  and  then  are  apt  to  be  deeply  excavated,  even  in 
tuberculous  cases. 

The  evidence  of  ulceration  in  the  trachea  is  sometimes  recog- 
nized with  the  laryngoscope,  but,  seen  as  it  is  in  perspective,  it 
afl^ords  a  vague  idea  only  of  the  extent  to  which  this  ulceration 
may  have  progressed.  The  post-mortem  appearances  often  ex- 
hibit a  much  greater  amount  of  destruction  than,  from  the  laryn- 
goscopic  appearances,  was  supposed  to  have  existed  during  life. 
Care  must  be  taken  not  to  mistake  as  ulcers  little  clumps  of 
mucus  adhering  to  the  various  parts.     The  application  of  a 


350        AFFECTIONS    OF   THE    LARYJSTX    AND    TRACHEA. 

moistened  sponge  or  of  a  shower  of  warm- water  spray  will  often 
cletach  the  mucus  and  show  tlie  membrane  beneath  to  be  un- 
abraded.  The  ulcers  are  almost  usually  covered  with  a  grayish 
or  ash-colored  pus,  which  presents  great  variety  of  appearance, 
and  upon  its  forcible  removal,  b}'^  compression  with  a  bit  of 
sponge,  the  ulcers  almost  invariabl}'  bleed,  but  not  freely.  These 
ulcers  are  sometimes  of  very  great  extent,  and  when  near  the 
points  of  articulation  of  the  cartilages  with  each  other  and  with 
the  vocal  cords,  are  apt  to  be  connected  with  necrosis  of  the 
(jartilage  from  ulcerative  perichondritis,  which  has  usually  pre- 
ceded their  formation.  In  tuberculous  cases  the  ulcerations 
heal  slowly,  and  often  reappear  in  the  same  or  other  situations. 
The  syphilitic  ulcer,  when  once  cicatrized,  is  aj)t  to  remain 
healed.  '  Ulceration  without  constitutional  taint  heals  readily 
and  permanently,  as  a  rule,  under  judicious  management. 

Besides  the  accumulations  of  mucus  in  the  interior  of  the 
larynx  proper,  there  is  almost  alwaj^s  to  be  observed  an  accumu- 
lation of  mucus,  or  mucus  and  saliva,  in  the  pyramidal  sinuses 
just  outside  the  lateral  walls  of  the  interior  of  the  larynx,  and  in 
the  valleculse  between  the  tongue  and  the  epiglottis.  Sometimes 
these  parts  participate  actively  in  the  diseased  condition,  and  are 
seen  to  be  inflamed  and  even  ulcerated.  Ulcers  in  these  loca- 
tions seem  to  be  more  amenable  to  treatment  than  the  intra- 
laryngeal  ulcers.  By  and  by,  as  the  disease  progresses,  it  is 
almost  certain  to  involve  the  pharynx,  palate,  and  all  the  adja- 
cent structures,  if  they  have  not  become  aifected  early  in  the 
complaint ;  and  ulcerations  occur  here  of  the  same  character  as 
Avithin  and  about  the  larynx. 

Deposits  of  the  products  of  infiannnation  occur  in  the  sub- 
mucous tissue  of  the  laryngeal  mucous  membrane,  and  this  to 
such  extent  sometimes  as  to  compromise  the  maintenance  of  the 
caliber  of  the  tube.  They  are  most  frequent  below  the  glottis, 
but  may  involve  the  lips  of  the  glottis  itself,  and  also  those 
portions  of  the  larynx  above  it.  This  produces  a  condition 
known  as  stenosis  of  the  larynx.  A  condition  of  stenosis  also 
occiu-s,  sometimes,  as  a  consequence  of  the  cicatrization  which 
takes  place  upon  the  healing  of  ulcerations,  or  of  parts  which 
have  suffered  injury  in  cases  of  wounds  or  fracture  of  the  larynx. 


CHRONIC    LARYNGITIS.  351 

The  symptoms  of  chronic  laryngitis,  at  first,  are  usually  alto- 
gether inadequate  to  explain  the  amount  of  disease  present,  even 
in  cases  of  ulceration  involving  the  vocal  cords  ;  unless  there  is 
extensive  ulceration  of  the  epiglottis,  giving  rise  to  dysphagia. 
In  ordinary  cases  tliere  exists  only  a  disagreeable  sense  of  un- 
easiness, with  moderate  hoarseness  and  a  sense  of  tickling,  which 
induces  an  irresistible  desire  to  cough.  There  is  usually  a 
copious  discharge  of  mucus  or  muco-piis,  which,  in  ulcerated 
cases  principally,  is  sometimes  streaked  with  blood.  The  ex- 
pectoration is  usually  most  copious  in  the  mornings,  from  ac- 
cumulation during  night. 

As  the  disease  progresses  these  symptoms  become  gradually 
more  and  more  distressing ;  the  general  system  becomes  affected 
with  irritative  fever,  which  often  assumes  the  periodical  char- 
acter and  is  accompanied  by  diaphoresis ;  the  pulse  rises  to  90, 
100,  112,  120  beats  in  the  minute,  and  keeps  there.  Symptoms 
of  gastric  and  intestinal  disorder  supervene.  The  cough  becomes 
more  troublesome,  painful,  and  of  longer  continuance;  the  par- 
oxysms of  cough,  towards  the  last,  bathing  the  patient  with 
sweat,  and  producing  great  debility,  so  that  finally  effective 
coughing  is  often  impossible.  The  dysphagia  becomes  intense 
as  the  ulceration  of  epiglottis  and  top  of  larynx  increases  in  ex- 
tent, so  that,  in  many  cases,  deglutition  finally  becomes  impos- 
sible, usually  first  as  regards  fluids,  and  afterwards  w^ith  solids 
also.  Everything  swallowed  is  painfully  regurgitated,  and  the 
thirst  cannot  be  allayed  by  ordinary  means,  so  that  the  p.atient 
often  perishes  from  actual  starvation. 

The  pain,  especially  when  the  epiglottis  is  deeply  ulcerated 
at  the  side,  runs  into  the  ears,  so  much  so  at  times  that  the 
patient  complains  much  more  of  the  pain  in  the  ears  than  of 
that  in  the  larynx ;  and  this  is  increased  by  swallowing  or  by 
local  applications,  and  is  dependent  on  irritation  of  the  auricular 
branch  of  the  pneumogastric  nerve,  probably  from  undermining 
of  the  tissues  in  its  neighborhood  by  extension  of  the  ulcerative 
process  outwards  towards  the  pharynx. 

The  voice,  which  at  first  is  perhaps  natural,  becoming  husky 
only  on  exertion,  gradually  becomes  habitually  hoarse,  and  may 
eventuallv  become  extinct.     The  character  of  the  voice,  how- 


352    AFFECTIONS  OF  THE  LAEYNX  AND  TRACHEA. 

ever,  does  not  depend  upon  the  amount  of  disease  present  in 
the  vocal  cords,  as  much  as  it  is  generally  supposed  to  do.  The 
voice  is  sometimes  perfectly  natural  when  the  cords  are  quite 
red  in  color ;  and  often  remains  tolerably  good  when  there  is  a 
considerable  amount  of  ulceration  upon  them.  Thickening  of 
the  vocal  cords  from  interstitial  deposit,  and  not  from  vascular 
turgescence  merely,  always  produces  hoarseness ;  and  their  de- 
struction by  ulcerative  action  entails  aphonia. 

Hoarseness  is  sometimes  j)i"esent  to  a  marked  degree  with 
very  little  evidence  of  disease  in  the  cords  themselves.  It  is 
probable  that  a  paralysis  occurs  from  deposition  of  inflamma- 
tory products  between  the  fibres  of  the  laryngeal  muscles ;  and 
sometimes  from  local  irritation  of  the  terminal  filaments  of  the 
nerves  of  the  larynx.  Under  these  circumstances  it  will  be 
understood  why  a  diminution  of  the  dysphonia,  so  often  present- 
ing in  chronic  disease  of  the  larynx,  or  a  return  of  voice,  as  it 
is  called,  is  by  no  means  indicative  of  an  improvement  as 
regards  the  local  progress  of  the  disease ;  and  this  will  be  found 
an  important  element  regarding  the  prognosis. 

On  the  other  hand,  the  vocal  cords  may  be  deeply  congested 
without  producing  a  marked  degree  of  hoarseness,  and  merely 
moderate  hoarseness  may  ensue  upon  extensive  ulceration  of 
the  tissues  of  the  cords.  The  character  of  voice,  therefore, 
cannot  give  any  certain  indication  of  the  condition  of  the 
vocal  cords,  which  is  to  be  learned  only  from  laryngoscopic 
inspection. 

Many  cases  of  chronic  laryngitis  appear  to  occur  without 
being  preceded  by  the  acute  disease  in  any  of  its  forms.  The 
story  will  run,  if  the  patient  was,  or  i-emains,  otherwise  in  com- 
parative good  health,  that  without  exposure  to  cold,  or  any  other 
accountable  cause,  there  gradually  arose  a  recognition  that  there 
was  some  slight  trouble  in  the  throat.  An  occasional  and  often 
momentary  hnskiness  of  voice  in  speaking,  an  occasional  expec- 
toration of  a  little  pellet  of  glairy  or  viscid  mucus,  with  a  sense 
of  dryness  in  the  throat,  leading  to  frequent  insalivation,  and 
now  and  then  a  slight  sense  of  impediment  to  respiration  at 
night,  the  patient  being  awakened  by  a  sense  of  suffocation,  as 
if  the  epiglottis  had  become  wedged  across  the  pharynx,  a  sensa- 


CHROlSriC    LAEYXGITIS.  353 

tion  readily  relieved  by  swallowing  saliva  or  a  draught  of  water. 
These,  perhaps,  would  be  all  the  inconveniences  that  the  patient 
would  be  conscious  of,  and  they  might  occur  so  seldom  that 
they  would  hardly  attract  notice  when  they  were  not  present. 
Then,  after  a  while,  soreness  supervenes,  or  occasional  pains  with 
increased  expectoration,  j^erhaps  with  entire  subsidence  of  the 
strangulating  spasm,  and  partial  subsidence  of  the  state  of  dry- 
ness.    In  some  cases  there  is  increased  dryness. 

In  this  state  the  patient  may  remain  for  years,  his  general 
health  unimpaired,  and,  the  condition  of  chronic  laryngitis 
having  become  constitutional,  suffering  but  little  with  his 
throat,  except  when  the  symptoms  of  his  disease  were  exasperat- 
ed by  over-exposure,  over-work,  or  over-indulgence. 

There  is  a  form  of  chronic  laryngitis  sometimes  met  with, 
most  frequently  in  young  adults  between  twenty  and  thirty 
years  of  age,  which,  although  attributed  by  the  jjatient  to  a 
severe  cold,  or  sore  throat,  as  the  initial  disturbance,  seems 
rather  to  be  due  in  great  part  to  over-feeding,  accompanied 
usually  with  the  abuse  of  condiments.  At  any  rate  it  appears 
to  be  kept  up  by  this  habit.  The  free  use  of  alcohol,  though 
indulged  in  in  many  of  these  cases,  is  not  an  essential  factor 
in  the  production  of  the  affection,  for  it  is  encountered  in  a 
marked  form  in  individuals  altogether  unaccustomed  to  the  use 
of  stinmlants.  In  these  cases,  there  is  usually  a  duskj'  hue  of 
the  skin,  and  perhaps  the  presence  of  sebaceous  follicles  or 
pimples  on  the  forehead  and  sides  of  the  face.  The  general 
health  is  good,  unless  we  except  a  tendency  to  costiveness, 
occasioning  resort,  now  and  then,  to  laxatives.  The  skin  is 
moist  and  the  extremities  warm.  The  pulse  is  usually  full  and 
slow.  The  tongue  is  red,  or  reddish-brown,  thick,  puffy,  the 
papillae  prominent,  and  it  is  covered  at  its  base  with  a  creamy 
fur,  which  projects  more  or  less  irregularly  in  streaks  towards 
the  tip.  In  some  cases  a  mere  inspection  shows  a  clean  tongue, 
but  an  examination  reveals  the  coating  at  the  base  of  the  organ. 
The  mucous  membrane  of  the  pharynx,  palate,  and  palatine 
arches  is  relaxed  and  puffy,  the  tonsils  often  a  little  en- 
larged, and  one  side  usually  more  so  than  the  other ;  and  the 
23 


354         AFFECTIOlSrS    OF    THE    LARYNX    AXD    TEACHEA. 

uvula  is  generally  relaxed  to  a  slight  degree.  The  follicles  of 
the  throat  are  not  prominent,  as  in  fcjllicular  pharyngitis,  but 
the  whole  membrane  looks  as  if  underlaid  by  a  layer  of  ef- 
fused lymph  bulging  the  mucous  membrane  forwards.  The 
posterior  portion  of  the  uvula  and  palate,  and  the  upjjer  portion 
of  the  pharynx,  as  well  as  the  naso-pharyngeal  region,  will  be 
found  in  the  same  puffy  condition.  Usually  the  parts  are  deeper 
in  color  than  is  normal,  but  very  often  the  color  is  unchanged. 
The  entire  larynx,  however,  is  always  congested,  and  the  vocal 
cords  are  pink  or  red  instead  of  being  white  or  whitish.  This  red- 
ness of  the  cords  is  greatest  at  their  arytenoidal  insertions,  so 
that  the  maculae  flavse  have  become  maculae  rubrse.  The  mu- 
cous membrane  covering  the  cartilages  of  Santorini  are  quite 
red  and  puffy,  and  a  similar  condition  extends  more  or  less 
along  the  whole  ary-epiglottic  fold.  A  streak  or  pellet  of 
mucus  often  occupies  the  inter-arytenoidal  commissure,  and 
mucus  is  often  also  adherent  along  the  lateral  walls  of  the 
larynx,  representing  accumulations  coughed  up  from  time  to 
time,  but  not  yet  coughed  out.  This  coughing  keeps  up  the 
congestion  of  the  larynx.  The  trachea  often  participates  in  the 
congestion.  The  mucus  in  the  trachea  is  very  adherent,  and 
seems  to  require  a  good  deal  of  effort  to  dislodge  it.  I  have 
watched  its  progress  up  the  trachea,  from  ring  to  ring  almost, 
gaining  a  little  at  each  cough,  until  finally  it  reaches  the 
larynx.  The  hoarseness,  in  this  complaint,  is  marked  and  con- 
stant ;  less  evident  in  singing  than  in  ordinary  conversation  ; 
more  marked  early  in  the  morning,  and  after  a  meal.  There  is 
a  sense  of  fulness  in  the  throat,  a  consciousness  of  the  presence 
of  a  layer  of  phlegm  to  be  hawked  up  or  coughed  up  with 
a  laryngeal  cough.  There  is  no  pain,  but  a  constant  conscious- 
ness of  an  uncomfortable  sensation,  which  is  very  annoying. 
Sleep  is  usually  good,  and  the  matters  are  expectorated  freely 
in  the  morning,  after  which  the  expectoration  is  light,  and 
sometimes  almost  unnoticed  for  the  rest  of  the  day.  It  usually 
comes  up  in  little  clumps  which  have  become  formed  by  the 
accumulations  coughed  from  time  to  time  into  the  larynx. 
These  are  usually  yellowish  in  color.     Sometimes  the  clumps 


CHEONIC    LARYNGITIS.  355 

expectorated  early  in  the  morning  are  brownish,  and  occasion- 
ally almost  black. 

In  other  cases  the  expectoration  is  more  profuse,  interfer- 
ing with  sleep ;  and  there  may  be  dyspepsia,  giddiness,  head- 
ache, and  more  or  less  manifestation  of  general  nervous  dis- 
turbance. This  condition  may  be  called  a  chronic  catarrhal 
laryngitis. 

The  treatment  that  I  have  fourd  most  efficient  under  these 
conditions  consists  in  an  inhalation  of  carbolic  acid  or  iodine, 
or  a  combination  of  the  two,  sometimes  of  muriate  of  ammonia, 
with  counter-irritation,  in  obstinate  cases,  at  the  nape  of  the 
neck  or  over  the  larynx  anteriorly. 

The  diet  is  to  be  restricted,  condiments  avoided,  and  stim- 
ulants interdicted;  and  to  assist  digestion,  five  drops  of  Fowlers 
solution  of  arsenic  may  be  taken  after  every  dinner  or  principal 
meal.  When  this  does  not  suffice,  ten  or  fifteen  grains  of  pep- 
sine  are  to  be  taken  with  each  meal,  and  each  meal  is  to  be 
followed  by  a  glass  of  water  acidulated  with  a  few  drops  of 
muriatic  or  nitro-muriatic  acid,  or  the  acid  phosphate  liquor. 
Where  there  is  a  good  deal  of  dyspepsia,  I  sometimes  order  dry 
cupping  over  the  stomach ;  and  where  there  is  a  tendency  to 
costiveness  or  actual  constipation,  generally  prescribe  an  ape- 
rient and  tonic  pill,  containing  podophyllin,  belladonna  or  hy- 
oscyamus,  extract  of  nux  vomica  or  of  ignatia  amara,  and  qui- 
nine, with  rhubarb  or  gentian  enough  to  make  the  mass ;  and 
recommend  the  free  use  of  water  between  meals. 

The  local  treatment,  if  required,  would  not  differ  from  that 
to  be  recommended  for  chronic  larvngitis  in  general. 

Thp  chronic  Laryngitis  of  Phthisis. — The  fact  that  various 
affections  of  the  larynx,  some  remediable  and  others  incurable, 
present  similar  subjective  symptoms  of  cough;  purulent  or  san- 
guineo-purulent  expectoration ;  impaired  respiration  ;  and,  when 
protracted,  diarrhcea  and  hectic,  accounts  in  great  part  for  the 
opinion  of  some  authors,  in  contrast  to  the  opinion  of  others, 
that  there  exists  a  special  disease  in  which  tuberculization,  if 
not  tubercle,  is  confined  to  the  larynx ;  which  disease  is  suscepti- 
ble of  cure. 


356        AFFECTIONS    OF    THE    LARYNX    AND    TRzVCHEA. 

Simple  chronic  laryngitis,  catarrhal  or  ulcerative,  is  often  a 
curable  affection  ;  but,  on  account  of  its  resistance  to  treatment, 
or  its  persistence  in  spite  of  it,  or  its  total  neglect,  proceeding 
gradually  from  bad  to  worse,  it  will  pi'oduce  the  subjective 
symptoms,  and  for  that  matter  all  the  objective  symptoms  also, 
which  writers  have  been  pleased  to  ascril)e  to  laryngeal 
phthisis. 

Should  asthma  coexist  with  chronic  laryngitis,  as  in  the  case  of 
a  young  lady  18  or  20  years  of  age,  recently  under  my  care,  it  will 
well  represent  the  symptoms  of  this  disease  as  ascribed  to  an  early 
stage  of  phthisis  laryngea  ;  and  the  analogy  is  greater  in  the  case 
alluded  to,  from  the  peculiar  hoarseness  so  much  dwelt  upon  in 
some  descriptions  being  here  caused  by  the  pressure  of  a  tumor 
the  size  of  a  large  j^ea,  situated  on  the  mucous  covering  of  the 
arytenoid  cartilage  and  the  inter-arytenoid  fold,  and  pressing 
upon  the  vocal  cord  of  the  right  side. 

A  deposit  of  tuberculous  matter  in  the  larynx  and  trachea 
does  not  often  occur,  as  a  general  rule ;  indeed  its  tendency  to 
deposition  in  these  localities  is  denied  by  some  authors  and 
doubted  by  others.  So  careful  an  observer  as  Dr.  S.  Scott 
Alison,  writes  ^  that  he  has  never  seen  tuberculous  matter 
grouped  in  masses  even  so  small  as  mustard-seeds  ;  and  that 
when  deposited,  it  seems  to  affect  very  iine  forms,  scarcely  visi- 
ble to  the  naked  eye,  such  as  he  has  observed  in  the  aorta  and 
pulmonary  artery  ;  l>ut  he  has  never  seen  anything  similar  to  the 
distinct  masses  of  tubercle  found  imbedded  in  the  mucous 
membrane  of  the  bowel.  Recently  some  obser\ers,  familiar 
with  the  use  of  the  laryngoscope,  report  that  they  have  detected 
\  tubercle  deposited  upon  the  mucous  membrane  of  the  larynx 

early  in  the  disease  ;  and  we  find  some  of  them,  as  Gibb.^  and 
Marcet,^  actually  depictingthem  in  their  illustrations  of  the  laryn- 
geal image.  Such  instances  must  be  rai-e,  for  of  the  hundreds  of 
cases  of  the  disease  under  consideration  which  the  writer  has 
had  occasion  to  examine,  he  cannot  recall  a  single  one  in  which 

'  Morbid  Conditions  of  the  Throat  in  their  Relation  to  Pulmonary  Consump- 
tion.    London,  1869,  p.  8. 

-  On  Diseases  of  the  Throat  and  Windpipe.     2d  edition.    London,  1804. 
^On  Diseases  of  the  Larynx.     London,  1809, 


THE    CHEOJN^IC    LAEYjSTGITIS    OF    PHTHISIS.  357 

the  larynx  was  studded  by  the  distinct  points  so  graphically  de- 
scribed by  the  authorities  cited,  and  by  others.  The  most  he 
has  seen,  and  that  very  rarely  indeed,  was  one  or  two,  or  perhaps 
as  many  as  thi-ee  or  four  isolated  white  spots  the  size  of  a  large 
pin's  head,  which,  in  cases  of  slowly  progressive  pulmonary  tuber- 
culosis, retaiiied  their  position  and  appearance  upcm  the  mucous 
membrane  of  tlie  laryngeal  walls,  without  change,  for  months 
and  months.  He  has  thought  these  might  have  been  degene- 
rated tubercles.  He  has  frequently  observed,  however,  in 
tuberculous  cases,  groups  of  enlarged  follicles  or  glands  over 
the  arytenoid  cartilages,  the  corpuscles  of  Santoi-ini,  and  occupy- 
ing the  lateral  walls  of  the  larynx,  which  presented  somewhat 
the  appearances  described  and  depicted  by  the  authors  in  ques- 
tion ;  but  he  has  never  had  reason  to  believe  them  to  be  tuber- 
cles, and,  with  due  deference  to  the  opinion  of  others,  has  held 
them  to  be  prominent  glands,  to  the  external  appearances  of 
which  a  yellowish  tinge  had  been  given  bythetensioii  of  the  mu- 
cous membrane  over  them.  A  similar  appearance  will  often  be 
found  in  some  simple  inflammations  occupying  the  lips,  the  in- 
side of  the  cheeks,  etc.,  which  occur  under  the  influence  of 
temperature,  indigestion,  or  overwork.  A  want  of  opportunity 
to  examine  such  a  condition  in  the  larynx  after  death  warrants 
a  mere  expression  of  opinion  only,  which  further  observation 
must  modify  or  confirm. 

The  author  discards  altogether  the  notion  of  any  distinct  dis- 
ease to  be  called  laryngeal  phthisis,  whether  it  be  the  tuber- 
culous ulceration  of  the  laryngeal  mucous  membrane  so  often 
observed  in  general  phthisis  early  in  the  disease,  or  whether  it 
be  the  extensive  ulcerative  chcmdritis  and  j)erichondritis  of  the 
older  authors.  It  is  altogether  doubtful  if  ever  a  case  existed 
in  which  tuberculous  disease  was  confined  to  the  laryngeal 
structures. 

It  is  very  rarely  indeed  that  we  meet  with  distinct  evidences 
of  tuberculous  deposit,  upon  laryngoscopic  inspection,  in  the  in- 
cipient stage  of  phthisis.  AVe  have  reason  to  suspect  that  such 
deposition  is  in  progress  Avhen  we  see  the  surface  of  the  anaemic 
mucous  membrane,  presenting  here  and  there  a  small  whitish 
prominence  the  size  of  a  pin-head  or   a  mustard-seed,  irregu- 


358         AFFECTIOJSrS    OF    THE    LARYKX   AND    TEACHEA. 

larly  oval  or  round  in  ontline,  and  looking  as  if  it  could  be 
popped  out  from  beneath  the  membrance  by  the  point  of  a 
bistoury.  Sometimes  we  see  groups  of  such  elevations.  They 
occur  on  the  epiglottis,  but  more  frequently  on  the  laryngeal 
surface  of  the  ary-epiglottic  folds,  on  the  ventricular  bands,  and 
on  the  inner  surface  of  the  corpuscles  of  Santoriui ;  but  they 
may  occur  in  any  portion  of  the  larynx.  These  have  been  sup- 
posed to  be  miliary  tubercles.  Occasionally  we  see  them  re- 
main without  any  change  in  appearance  for  months,  conveying 
the  impression  that  they  are  calcareous  degenerations  of  former 
tubercles.  It  is  likely  that  they  are  occasionally  discharged  and 
expectorated,  though  no  instance  of  the  kind  has  come  under 
the  observation  of  the  author. 

More  frequently  we  observe  an  anaemic  appearance  of  the  en- 
tire mucous  membrane  of  the  larynx,  the  mucous  membrane  of 
the  pharynx  being  in  a  similar  condition.  Accompanying  this 
condition  we  see  an  irregular  vascularity  of  portions  of  the  mucous 
membrane,  which  here  and  there  is  elevated  in  irregular  ridges, 
or  clumps  of  a  distinctly  velvety  appearance,  red  in  color,  and 
conveying  the  impression  of  denuded  epithelium.  There  is 
often  a  general  swollen  condition  of  the  mucous  membrane,  but 
it  is  by  no  means  constant.  The  most  frequent  locality  of  swel- 
ling, perhaps,  is  upon  the  surfaces  of  the  cartilages  of  Santorini, 
which  are  converted  into  irregularly  rounded  cushions,  very 
red,  sometimes  fiery  red ;  and  not  unfrequently  actually  livid 
at  the  points  where  they  press  together  in  phonation  and  in 
deglutition.  Occasionally  the  epiglottis  will  be  quite  flaccid, 
presenting  a  marked  contrast  to  its  ordinary  condition  of  stiff- 
ness. The  inter-arytenoidal  fold  is  very  apt  to  participate  in 
this  condition,  and  will  be  usually  red,  often  mth  irregular 
projections  on  its  laryngeal  face,  which  projections  in  some 
instances  gradually  assume  the  appearance  of  small  warts  or 
vegetations,  the  o-rowth  of  which  is  sometimes  accelerated,  and 
again  retarded  during  the  course  of  the  disease.  This  point, 
the  laryngeal  face  of  the  inter-arytenoidal  fold,  is,  Avhen  the 
seat  of  disease,  almost  constantly  covered  by  a  thin  layer  of 
mucus,  or  muco-pus,  or  pus,  which  gradually  trickles  over  the 
bridge  of  tissue  into  the  pharnyx,  and  occasionally  when  wiped 


THE    CHRONIC    LARYNGITIS    OF    PHTHISIS.  359 

clean  with  a  sponge,  discloses  an  irregular  ulceration  of  the 
membrane.  There  is  usually  a  thinner  layer  of  mucus  bathing 
the  interior  of  the  larynx  to  a  greater  or  less  extent,  with  often 
small  clumps  of  thicker  mucus  clinging  to  the  edges  of  the 
vocal  cords,  much  in  the  same  manner  as  a  viscid  material  such 
as  molasses  would  cling  to  the  fingers  when  pressed  together 
and  separated.  The  vocal  cords  are  usually  more  or  less  con- 
gested and  sometimes  intensely  so,  so  that  they  are  as  deep  in 
color  as  the  general  laryngeal  nnicous  membrane,  and,  if  the 
latter  be  at  all  anaemic,  even  of  a  deeper  red.  Sometimes  they 
are  studded  with  points  of  ecchymoses. 

At  a  later  stage  of  the  affection,  the  velvety  projections  of 
the  mucous  membrane  undergo  abrasion,  and  ulcers  are  left, 
varying  in  shape  and  position.  The  mucous  membrane  upon  the 
vocal  cords  finally  gives  way  also,  and  we  find  ulcers  upon  these 
structures.  Sometimes  the  membrane  gives  Avay  at  the  very 
edges  of  the  cords,  and  leaves  them  with  an  irregularly  jagged 
or  toothed  border,  looking  not  unlike  a  shred  of  scolloped  mus- 
lin, from  which  some  of  the  transverse  threads  have  been  drawn 
out.  These  jDrojections  present  favorable  j^oints  for  the  accumu- 
lation of  the  viscid  secretions  of  the  larynx  ;  so  that  there  arises 
frequent  occasion  to  clear  the  glottis  from  the  clumps  of  mucus 
wliich  adhere  to  its  lips,  and  produce  irritation  and  irrepressible 
cough.  The  lateral  walls  of  the  larynx  now  show  increased  swel- 
ling, and  the  ventricular  bands  project,  sometimes  on  both  sides, 
but  more  frequently  on  one  side  only,  into  the  interior,  so  as  to 
cover  the  vocal  cords  more  or  less  completely,  and  their  borders 
approximate  in  closure  of  the  glottis  before  those  of  the  vocal 
cords  themselves ;  and  they  not  unfrequently  exhibit  a  dull 
grayish  aspect,  and  are  sometimes  covered  with  an  ash-colored 
membranous  deposit.  iSTot  infrequently  the  line  of  demarcation 
between  ary-epiglottic  fold  and  ventricular  band  is  entirely 
obliterated.  The  general  signs  of  inflammation  in  the  larynx 
increase ;  we  find  the  epiglottis  invaded,  its  edges  becoming 
inflamed  or  ulcerated,  as  also  its  laryngeal  face  ;  the  outer 
surface  of  the  larynx  becomes  implicated  ;  the  purulent  or 
muco-purulent  secretion  accumulates  in  the  pyramidal  sinuses 


3 GO         AFFECTIOI^S    OF    THE    LARYNX   Al^-D    TRACHEA. 

which  are  sometimes  filled  with  it,  and  in  the  glotto-epig-lottic 
sinuses  ;  and  the  swollen  structures  become  more  and  more  irreg- 
ular and  deformed  in  outline,  so  that  it  is  extremely  difficult 
to  describe  or  depict  the  altered  appearance  of  the  parts.  Some- 
times we  find  the  ventricular  band  adherent  to  the  vocal  cord 
below  it,  obliterating  the  ventricle ;  with  this  condition,  and 
also  sometimes  independently  of  it,  we  see  one  vocal  cord 
raised  higher  than  its  fellow,  preventing  their  proper  a].>proxi- 
mation,  and  producing  persistent  dysphonia.  This  condition 
will  sometimes  be  perceived  at  a  very  early  stage  of  the  disease, 
when  the  only  subjective  syuiptom  will  be  the  hoarseness. 
Eventually,  however,  unless  retarded  by  general  hygienic  treat- 
ment or  local  astringents,  other  symptoms  gradually  appear, 
finally  leaving  no  doubt  as  to  the  tuberculous  nature  of  the  af- 
fection. Irregular  granulations  are  disposed  to  spring  up  about 
the  bases  of  tlie  tuberculous  ulcerations,  or  around  their  edges, 
forming  veritable  neoplasms,  usnall}'  containing  epithelial  ele- 
ments under  the  microscope,  and  showing  a  marked  disjDOsition 
to  repullulation  from  their  base  as  fast  as  they  may  be  torn  off 
by  forceps,  or  destroyed  by  caustics,  procedures  which  become 
often  necessary  for  the  relief  of  dyspnoea,  and  of  tickliug  sen- 
sations exciting  irrepressible  cough.  These  are  found  perhaps 
most  fi'equently  upon  the  inter-arytenoid  fold,  but  also  on  the 
inner  surfaces  of  the  arytenoid  cartilages,  on  the  posterior  edges, 
and  inferior  face  of  the  vocal  cords,  sometimes  at  the  anterior 
angle  of  the  vocal  cords,  at  the  base  of  the  epiglottis,  sometimes 
near  the  edge  of  the  epiglottis  on  its  laryngeal  face,  aud  upon 
the  surface  of  the  ventricular  bands.  Again  and  again  I  ha^-e 
seen  them  sprout,  fungus-like,  from  the  bed  of  the  ulcer,  and  in- 
crease in  size  from  week  to  week.  Sometimes  these  vegetations 
appear  without  any  evidence  of  ulcerative  action  present  or 
past,  and  when  pulled  oft"  become  the  starting-point  of  ulcera- 
tive action  which  might  not  otherwise  have  Ijeen  excited  until 
a  subsequent  period  of  the  disease.  Some  cautiou  is  therefore 
necessary  in  interfering  surgically  with  these  vegetations  when 
present  in  a  case  of  phthisis ;  and  it  is  ouly  when  they  are  of 
a  size  to  present  considerable  interference  Avith  the  functions  of 
the  parts,  tliat  they  are  to  be  attacked  ;  for  sometimes,  under  a 


THE    CHEOXIC    LARYNGITIS    OF    PHTHISIS. 


361 


judicions  management  of  the  general  condition,  and  the  inhala- 
tion of  gently  stimulating,  astringent,  or  absorbent  remedies, 
they  slowly  disappear  without  the  aid  of  cautery  or  foi'ceps. 

Ulcerative  action,  when  once  set  up  in  the  laryngitis  of 
phthisis,  is  exceedingly  difficult  of  control.  It  is  apt  to  sur- 
mount the  laryngeal  wall,  posteriorly  or  laterally ;  and  it  then 
presents  an  impediment  to  deglutition,  and  a  provocation  to 
vomiting;  conditions  of  affairs  which  grow  steadily  from  bad 
to  worse,  until  finally  it  becomes  impossible  to  nourish  the 
patient  by  the  stomach,  or  even  to  cpiench  his  thirst  with  a 
glass  of  water.  Almost  every  particle  attempted  to  be  swal- 
lowed is  regurgitated  with  violence,  sometimes  into  the  larynx, 
sometimes  into  tlie  nostrils,  sometimes  both  ways  at  once,  pro- 
ducing intense  spasmodic  paroxysms  of  cough,  dyspnoea,  and 
local  distress,  so  that  the  suffering  of  hunger  and  thirst  will  be 
endured  as  long  as  possible,  before  the  afflicted  patient  resorts 
to  a  temporary  alleviation,  which  is  to  be  purchased  only  at  the 
expense  of  a  repetition  of  the  dreaded  paroxysms.  The  ap- 
proach of  inevitable  death,  often  long  postponed,  is  awaited 
with  bitter  satisfaction,  in  the  knowledge  tliat  an  end  to  tlie 
suffering  must  come,  and,  if  consciousness  remains  to  the  last,  it 
is  with  a  sigh  of  relief  that  the  patient  expires.  While  the 
patient  is  in  this  condition,  but  little  can  be  seen  of  the  in- 
terior of  the  larynx  ;  and  the  enlarged  area  of  the  arytenoid 
and  Santorini  structures,  the  cartila- 
ges of  which  are  probably  undergoing 
caries,  the  swollen  folds  forming  the 
lateral  walls,  and  other  cedematous 
structures  are  so  covered  with  mucus 
and  pus,  that  no  definite  idea  can  be 
obtained  of  their  condition,  other 
than  of  the  general  nature  of  the  im- 
pediment which  they  present  to 
respiration  and  deglutition.  Fig.  63, 
from  one  of  the  author's  cases,  re- 
presents a  common  appearance  of 
this  condition. 

Necrosis  and  discharge  of  the  laryngeal  cartilages  is  also  apt 


Laryngoscopic  appearance  of  ffidema 
of  Larjnx  with  ulceration,  in  the  latter 
stage  of  phthisis. 


362        AFFECTIOlSrS    OF    THE    LARYNX   AISI^D    TEACHEA. 

to  follow  if  the  patient  survives  long  enongh  for  the  necessary 
changes  to  take  place. 

Phthisis,  attended  with  the  lar^^ngeal  complications  just 
enumerated,  is  apt  to  be  chronic  in  its  character,  continuing  for 
a  number  of  years,  varying  say  from  two  or  three,  to  seven  or 
eight ;  and  is  always  attended  finally  with  extensive  ulceration 
of  the  trachea,  in  parts  of  ten  beyond  the  reach  of  laryngoscopic 
exploration,  ulceration  sometimes  productive  of  perforation  into 
the  oesophagus. 

In  the  earliest  stages  of  the  disease,  the  affection  is  usually 
confined  to  one  side,  and  that,  the  side  on  which  the  disorgani- 
zation is  taking  place  in  the  lungs.  Subsequently  the  other 
side  is  attacked  likewise. 

A  brief  transcript,  from  some  of  the  notes  in  my  case-books, 
will  illustrate  the  character  of  the  laryngeal  ravages  met  with 
in  this  form  of  phthisis. 

1.  Oct.  21,  1866.  A  stout  farmer,  about  forty  years  of 
ao-e,  and  weighing  190  lbs.  Laryngitis  of  three  years'  duration. 
Condensation  in  upper  lobe  of  right  lung.  Ulcerations  on 
right  vocal  cord,  right  ventricular  band,  and  right  glotto-epi- 
glottic  fold  and  sinus.  Ultimately  died  of  phthisis  pulmo- 
nalis. 

2.  Nov.  14, 1866.  A  female  detective,  jet.M.  Married.  Placed 
under  my  care  by  Prof.  H.  II.  Smith.  Softening  and  vomicae 
on  left  side.  A  large  ulcer  on  the  inner  surface  of  the  left 
arytenoid  cartilage,  and  covered  with  a  cheesy-looking  deposit ; 
posterior  portion  of  vocal  cord  of  same  side  ragged,  as  though 
eaten  out  by  •  ulceration.  Dec.  27th,  cheesy  deposit  now  on 
right  arytenoidal  wall.  Jem.  16th,  1867,  both  arytenoid  carti- 
lages oedematous,  and  s\^'ollen  to  at  least  four  times  their  normal 
dimensions  ;  these  oedematous  swellings,  both  ventricular  bands, 
and  both  vocal  cords,  covered  with  an  ash-colored  membranous 
deposit.     Death,  Jan.  "iUh.     No  autopsy. 

3.  *  *  Cynthia  W.  *  *  "'"  Epiglottis  bent  over  to  left 
side  ;  ulceration  over  entire  quadrangular  membrane  of  that 
side  ;  ulceration  of  left  ventricular  band  ;  partial  loss  of  left 
vocal  cord  by  ulceration.  Pulmonary  ravages  also  on  left  side. 
Termination  unknown,  but  supposed  to  have  been  fatal. 


THE    CHROlSriC    LARYNGITIS    OF    PHTHISIS.  363 

4.  A.  R.,  fireman,  set  28.  Epiglottis  bent  to  right  side  ;  ul- 
ceration of  left  side  of  larynx,  with  purulent  discharge  from 
left  ventricle  ;  ulcers  on  left  vocal  cord  ;  j)us  in  left  pyriform 
sinus  ;  vomicae  in  left  lung ;  softening  in  right  lung.  Death 
within  a  few  months. 

5.  *  *  *  QEdematous  epiglottis,  and  ulceration  of  glosso- 
e23iglottic  sinuses. 

6.  Oct.  25,  1867.  Mary  L.,  set  17,  in  advanced  stage  of 
phthisis  ;  tubercles  disseminated  throughout  both  lungs.  This 
patient  had  been  brought  many  miles  for  examination  on  ac- 
count of  complete  aphonia,  moderate  dyspnoea,  and  some  dys- 
phagia. The  epiglottis  was  swollen  to  a  size  larger  than  a 
man's  thumb  ;  it  was  fan-shaped,  and  could  be  seen  projecting 
behind  the  tongue,  on  mere  inspection  without  using  the  lai-yngo- 
scope.  Both  aryteno-epiglottic  folds  were  oedematous.  This 
patient  was  very  wilful,  and  would  not  permit  an  attempt  at 
scarification  of  the  parts,  which  would  have  afforded  her  great 
relief.  Some  finely  pulverized  tannin  was  propelled  upon  the 
parts,  which  produced  marked  diminution  of  her  distress  at 
once,  with  partial  restoration  of  voice.  The  patient  returned 
home  next  day,  and  died  shortly  afterwards,  without  having  had 
any  evidence  of  increase  in  the  local  symptoms. 

7.  *     *     *     *     1867.     CEdema  of  palate  and  epiglottis. 

g^  ^  -X-  -X-  -X-  1867.  Mr.  E.,  of  Harrisburg^  was  ex- 
amined by  me  at  request  of  Prof.  Gross.  There  was  aphonia 
and  dysphagia  of  two  months'  duration,  attributed  to  a  cold. 
The  only  thing  the  patient  could  swallow,  without  distress,  was 
iced-water.  There  was  great  oedema  of  the  epiglottis,  cutting 
oif  the  view  of  everything  else  except  the  posterior  portions  of 
the  vocal  cords,  which  were  gray,  and  bathed  in  pus,  as  were 
also  the  swollen  corpuscles  of  Santorini.  The  pharynx  was  in- 
flamed, but  presented  no  abrasions.  In  order  to  obtain  a  view 
of  the  parts,  it  was  found  necessary  to  place  the  eye  at  a  lower 
level  than  the  patient's  mouth,  and  to  look  upwards  upon  the 
mirror.  There  was  abundant  evidence  of  tuberculous  deposit 
in  the  lungs ;  and  the  patient  succumbed  a  few  months  after- 
wards, 

9.   IVov.  14,  1867.     Mrs  ^Y.,  sent  by  Dr.  Patski.     Epiglottis 


3f34         AFFECTIOlSrS    OF    THE    LARYNX    AIN^D    TRACHEA. 

ulcerated  on  the  laryngeal  face,  and  adherent  to  the  tongue  in  its 
lingual  surface  ;  uvula  swollen  and  bifid  ;  throat  difficulty  of  six 
months'  duration,  attended,  for  three  weeks,  with  great  dysphagia 
in  swallowing  solids  as  well  as  fluids.     Termination  unknown. 

10.  *  *  *  -  j^t.  26.  Examined  for  Dr.  Tyson. 
OEdema  of  epiglottis  and  of  both  arytenoids,  preventing  view 
into  interior  of  larynx.  Parts  anaemic.  Complete  aphonia. 
Pus  running  over  inter-arytenoid  fissure  into  pharynx.  Termi- 
nation unknown,  but  believed  to  have  been  fatal. 

It  is  a  matter  of  indifference  whether  "  tuberculous  laryngi- 
tis," as  it  is  called,  is  a  disease  of  itself,  or  dependent  upon  a 
tuberculous  condition  of  the  lungs.  The  essential  malady  is 
one  and  the  same  thing ;  and  sooner  or  later,  either  before  the 
appearance  of  the  laryngeal  ulcerations,  or  during  their  progress, 
the  pulmonary  symptoms  become  manifest.  Many  cases  of 
pulmonary  tuberculosis  proceed  to  their  fatal  issue  without  any 
involvement  of  the  larynx ;  but  in  most  of  them,  if  their  stages 
are  completed,  the  larynx  becomes  involved  towards  the  close, 
if  not  sooner.  When  the  larynx  is  involved,  the  disease  becomes 
a  very  serious  one  indeed,  rarely,  if  ever,  curable,  and  sometimes 
insusceptible  of  amelioration  or  relief.  At  tiines  the  laryngeal 
symptoms  recede  for  a  while,  local  remedies  seeming  to  rej^ress 
the  local  manifestations  ;  and  when  this  is  the  case,  it  is  usually 
evident,  at  the  same  time,  that  the  pulmonary  complications  are 
progressing  anew.  Sometimes  the  pulmonary  difficulty  dimin- 
ishes while  the  throat  trouble  increases ;  at  other  times  they  ad- 
vance together  in  spite  of  the  best-directed  efi^orts.  Occasionally 
the  throat  becomes  healed  without  any  advance  in  the  disease  of 
the  lungs  ;  and  in  rare  instances  the  disease  seems  to  be  arrested 
in  both  localities.  I  have  records  of  a  few  instances,  still  under 
occasional  observation,  in  which  the  improvement  has  been 
steadily  maintained  for  three  and  four  years ;  two  or  three  of 
them  for  a  longer  time  ;  and  in  whom  there  has  not  been,  in  all 
this  period,  any  manifestation  of  an  advance  in  the  affection. 
Statistics,  however  valuable  they  may  be  for  tabulation,  are  of 
little  use  iu  forming  a  prognosis  with  reference  to  any  individual 
case  of  this  kind.    Under  my  own  hands,  two  very  unpromising 


THE    CHROiS^IC    LAEYISTGITIS    OF    PHTHISIS.  365 

cases,  and  one  particularly  so,  in  which  I  could  not  refrain  from 
a  decidedly  inifa\orable  prognosis,  improved  steadily,  much  to 
my  surprise  and  almost  against  hope,  under  the  use  of  cod-liver 
oil  internally,  inlialations  of  carbolic  acid,  and  local  applications 
of  nitrate  of  silver.  On  the  other  hand,  and  what  is  more  to  the 
point,  I  have  often  signally  failed  in  restraining  the  onward 
progress  of  destruction  in  cases  apparently  favorable  for  im- 
provement, and  where  there  was  every  reason  to  hope  for  it, 
from  family  history,  physical  condition,  integrity  of  digestive 
powers,  and  ability  and  willingness  to  second  in  every  way  the 
efforts  of  the  physician. 

Local  treatment  to  the  larynx,  such  as  is  described  under  the 
head  of  treatment  of  chrOnic  laryngitis,  is  often  of  benefit  to 
the  patient  in  the  laryngitis  of  phthisis,  though  inadequate  to  a 
cure  of  the  disease.  There  often  coexists  in  these  cases  a 
similar  condition  of  the  entire  trachea,  which  cannot  be  reached 
except  in  general  medication  of  the  upper  air-passages  by  in- 
jection, insufflation,  or  inhalation. 

In  some  conditions  of  laryngitis  associated  with  phthisis,  there  is 
a  predisposition  to  the  involvement  of  the  cartilage,  in  the  form 
of  a  chondritis  or  perichondritis,  set  up  either  as  a  primary 
aifection,  or,  as  appears  to  be  the  case  in  some  instances,  result- 
ing from  extension  of  the  disease  already  existing  in  the  soft 
structures.  This  is  the  laryngeal  phthisis  of  the  older  writers, 
to  which  allusion  has  already  been  made.  These  cases  are 
particularized  by  the  great  extent  to  which  the  cartilages  are  in- 
volved, denuded,  and  discharged.  All  the  cartilages  are  subject 
to  this  perichondritis,  the  arytenoid  cartilages,  perhaps,  especially. 
As  these  cartilages  are  the  levers  which  move  the  vocal  cords  to 
and  fro,  we  can  understand  how  their  free  outward  and  inward 
motion  is  impeded  by  swelling,  thus  producing  more  or  less  im- 
pairment of  voice ;  and  we  can  recognize  the  cause  of  the 
complete  aphonia  which  usually  ensues  on  their  destruction. 
Aphonia  is  not  always  a  necessary  result  of  the  loss  of  the 
arytenoid  cartilages,  for  inflammatory  adhesions  may  have  taken 
place  during  the  discharge  of  the  cartilage,  pinning  the  vocal 
cords,  as  it  were,  to  the  mucous  membrane,  which  then,  with 
an  intervening  deposit  of    organized   products  of  infiltration, 


366        AFFECTIOITS    OF    THE    LARYNX    AND    TEACHEA. 

answers  the  purpose  of  an  imperfect  cartilage.  This  affection 
is  recognized  in  the  laryngoscopic  mirror,  at  the  posterior  portion 
of  the  laryngeal  enti-ance,  by  the  oedematous  swelling  of  the 
parts,  about  which  some  point  of  ulceration  can  usually  be 
detected. 

The  cricoid  cartilage  suffers  sometimes  primarily  and  some- 
times apparently  as  an  extension  from  the  disease  affecting  the 
arytenoids.  The  condition  is  recognized  by  a  swollen  or  ulcer- 
ated appearance  of  the  part,  as  the  case  may  be,  within  the 
larynx  and  beneath  the  vocal  cords,  or  bulging  up  between 
them. 

The  thyroid  cartilage  is  sometimes  affected,  usually  at  its 
anterior  portion,  just  below  the  position  of  the  vocal  cords. 
Sometimes  the  disease  extends  to  the  anterior  perichondrium, 
and  thence  into  the  subcutaneous  tissue,  giving  rise  to  a  fistule. 
Prof.  Rokitansky  has  recorded  a  case  of  emphysema  originating 
in  this  maimer. 

The  epiglottis,  when  the  seat  of  perichondritis,  is  converted 
into  a  thiclc,  ungainly  pad,  usually  bent  upon  itself,  larger  on 
one  side  than  the  other,  and  almost  always  preventing  a 
satisfactory  view  into  the  larjaix  ;  though  usually  some  portion 
of  the  glottis  can  be  seen,  enough  to  enable  us  to  judge  of  its 
condition  of  integrity  or  deficiency.  Sometimes  the  epiglottis 
is  attacked  separately;  but  more  frequently  in  connection 
with  more  or  less  disease  of  a  similar  character  affecting  the 
arytenoid  cartilages,  or  at  least  the  cartilages  of  Santorini.  In 
connection  with  the  inflammatory  condition  of  these  affections, 
there  is  more  or  less  oedema  of  the  parts,  attended  with  all  the 
symptoms  and  risks  of  that  condition.  The  diagnosis  of  peri- 
chondritis is  usually  confirmed  by  the  pain  and  tenderness 
produced  by  external  pressure  upon  various  portions  of  the 
larynx,  and  by  moving  it  gently  from  side  to  side. 

The  disease  progresses,  if  the  patient  lives  long  enough,  until 
the  diseased  or  dead  cartilage  is  expelled  ;  and  then  the  patient 
runs  the  risk  of  suffocation  during  its  expulsion.  Sometimes,  how- 
ever, the  necrosed  cartilage  has  been  recognized  in  the  mirror, 
and  under  these  circumstances  the  progress  towards  its  detach- 
ment can  be  watched,  and  be  occasionally  assisted  by  the  for- 


THE    CIIEONIC    LARYNGITIS    OF    SYPHILIS.  367 

ceps.  Should  symptoms  of  dyspnosa  be  seen  to  be  due  to  im- 
paction of  cartilage,  unfavorably  disposed  for  extraction  by 
forceps,  tracheotomy  is  demanded  to  insure  the  safety  of  the 
patient. 

When  the  cartilage  has  been  discharged,  the  local  and  gene- 
ral symptoms  of  the  patient  improve  at  once,  especially  if  there 
be  no  necrosis  going  on  elsewhere  ;  so  that  he  seems  to  have 
gained  a  fresh  lease  of  life. 

Usually,  however,  the  disease  is  inevitably  and  progressively 
fatal ;  and  after  death,  evidences  are  found  of  extensive  partici- 
pation in  the  disease  on  the  part  of  the  rings  of  the  trachea, 
portions  of  which  are  not  unfrequently  detached  and  ex- 
pectorated during  the  life  of  the  patient. 

Gangrene  of  the  larynx  sometimes  occurs.  Porter,'  men- 
tions a  case  in  a  male,  set.  65,  who  died  in  Meath  hospital  with 
gangrene  of  the  lung,  and  who  had  exhibited  marked  and 
increasing  evidence  of  distress  in  the  larynx  for  seven  days 
previous  to  his  death.  On  examining  the  larynx,  a  gangrenous 
ulcer  was  found  involving  the  left  vocal  cord,  in  superficial 
surface  about  the  size  of  a  shilling,  and  of  a  dirty  green  color ; 
its  edges  quite  sloughy,  and  its  centre  excavated  to  a  consider- 
able depth ;  the  mucous  membrane  around  highly  vascular,  and 
covered  with  a  pellicle  of  lymph. 

The  Chronic  Laryngitis  of  Syphilis.— This  affection,  as 
alread}^  stated,  cannot  with  certainty  be  distinguished  from 
other  forms  of  chronic  laryngitis,  by  ocular  inspection  only. 
This  is  especially  so  in  those  cases  where  syphilitic  and  tuber- 
culous laryngitis  coexist.  The  history  of  the  case,  and  the  evi- 
dence of  analogous  disease  elsewhere,  will  aid  the  diagnosis, 
and  if  this  be  correct,  the  treatment  will  prove  it,  if  the  case 
has  not  progressed  beyond  the  susceptibility  to  cure.  The 
general  appearances  having  been  already  discussed,  some  special 
j)oints  only  require  mention  here.  In  the  extensive  ulcerations 
that  accompany  tertiary  syphilis,  and  which  may  attack  any 
portion  of  the  larynx,  we  sometimes  notice  deep  excavations, 
with  undermined  edges,  more  or  less  rounded  in  their  visible 
'  On  the  Larynx  and  Trachea,  p.  122. 


368         AFFECTIONS    OF    THE    LAEYNX    AND    TRACHEA. 

outline,  and  covered  with  a  gravisli  or  grayish- yellow  deposit ; 
peculiarities  which  are  regarded  as  characteristic.  The  exist- 
ence, too,  of  cicatrizations,  marl^;ing  the  locality  of  former  ulcers, 
is  almost  presumptive  evidence  of  syphilis,  inasmuch  as  ulcera- 
tions of  the  larynx  rarely  heal  during  the  active  progress  of 
tuberculosis  or  carcinoma.  It  is  usually  associated,  in  its  later 
manifestations,  with  syphilitic  inflammation  of  tlie  hard  and 
soft  tissues  of  the  mouth,  palate,  and  pharynx,  and  sometimes 
Avith  actual  necrosis  and  discharge  of  the  anterior  portions  of 
the  cervical  vertebrae.  The  ulceration  extends  deeply  and 
widely  ;  in  the  one  instance  producing  destruction  of  the  car- 
tilages, and  in  the  other,  ulcerations  of  such  large  surface,  that 
in  their  cicatrization  the  dimensions  of  the  laryngeal  cavity  are 
considerably  encroached  upon,  to  such  an  extent,  in  some  in- 
stances, as  to  demand  the  operation  of  tracheotomy.  With  the 
exception  of  the  epiglottis,  the  cartilages  of  the  larynx  are  eaten 
out  of  their  investments,  as  it  were  ;  that  is  to  say,  an  ulcera- 
tion extends  into  the  cartilage,  and,  if  small,  surrounds  it,  or, 
if  it  be  a  large  cartilage,  circumscribes  a  portion  of  it ;  this 
portion,  within  the  zone  of  the  local  process,  perishes,  is  laid 
bare,  and  becomes  detached  from  its  connections,  remaining,  in 
some  instances,  entangled  in  a  sort  of  pocket  scooped  out  of  the 
soft  tissues.  The  necrosed  cartilage  finally  breaks  through  to  the 
interior,  and,  if  it  be  situated  below  the  glottis,  may  induce 
paroxysms  of  suffocation,  or  actual  asphyxia  from  its  presence 
as  a  foreign  body.  The  arytenoid  cartilages  and  the  cricoid  are 
those  which  are  most  apt  to  produce  this  complication,  though 
occasionally  it  is  effected  by  exfoliation  of  part  of  the  thyroid. 
Sometimes  the  inflammation  begins  in  the  external  perichon- 
drium of  the  cartilage,  and  the  resulting  abscess  bursts  exter- 
nally, so  that  the  necrosed  cartilage  is  removed  in  this  way. 
The  epiglottis,  though  sometimes  attacked  on  its  laryngeal  face 
in  this  same  manner,  seems  more  disposed  to  undergo  pro- 
gressive destruction  from  the  side  ;  the  diseased  process  being 
directed  that  way,  perhaps,  in  consequence  of  the  direct  lateral 
connections  of  tlie  epiglottis  with  the  j)harynx.  Sometimes  the 
entire  epiglottis  is  destroyed,  leaving  a  mere  stump  to  repre- 
sent the  organ.  This,  however,  does  not  prevent  deglutition, 
and  sometimes  does  not  even  interfere  with  it. 


THE    CHROIS^IC    LARTIS'&ITIS    OF    SYPHILIS.  369 

The  result  of  the  chondritis  or  perichondritis,  which  is  set  up 
primarily  bv  the  syphilitic  poison,  or  which  follows  syphilitic 
ulceration  of  the  mucous  membrane,  produces  more  or  less 
submucous  infiltration  in  the  adjacent  submucous  tissue,  pre- 
senting a  condition  which  may  be  regarded  as  chronic  oedema. 
This,  if  extensive,  produces  all  the  symptoms  narrated  under 
the  caption  of  osdematous  laryngitis,  and  may  necessitate 
tracheotomy.  Sometimes  blood-vessels  are  opened  by  the  ulcer- 
ative process,  and  hemorrhage  is  produced,  which  is  sometimes 
fatal.  The  trachea  participates  in  the  ulcerative  action  ;  portions 
of  its  cartilages  are  necrosed  and  expectorated,  and  extensive 
ulcers  are  formed,  the  cicatrization  of  which  produces  constric- 
tion or  stenosis  of  the  windpipe,  which,  when  low  down,  is  often 
beyond  remedy,  even  by  the  performance  of  tracheotomy  ;  the 
parts  being  illy  suited  for  improvement  from  artificial  dilatation. 

Sometimes  the  matters  in  the  submucous  infiltration  become 
organized  and  transformed  into  a  fibrous  tissue  incapable  of 
undergoing  absorption,  and  thas  producing  permanent  defor- 
mity and  constriction  of  the  larynx. 

There  are  often  several  ulcers  occupying  different  portions  of 
the  larynx,  and  not  at  all  confined  to  one  side ;  indeed  they  are 
perhaps  more  inclined  to  be  symmetrically  arranged  than  are 
the  ulcerations  of  tuberculosis. 

The  tendency  of  syphilitic  laryngitis  to  excite  inflammation, 
leading  to  the  deposition  of  fibrine,  which  l)ecomes  organized, 
and  contracts  permanent  adhesions  to  the  walls  of  the  larynx, 
and  by  its  subsequent  contraction  tending  to  bring  these  walls 
into  closer  contact,  is  very  great,  and  we  often  meet  with  con- 
traction of  the  calibre  of  the  tube  from  this  cause — stenosis,  as 
it  is  technically  called — which,  even  when  attended  to  early, 
does  not  often  yield  to  systematic  artificial  dilatation,  but  usually 
necessitates  a  resort  to  tracheotomy,  for  the  purpose  of  securing 
respiration  through  a  metallic  canide  inserted  into  the  windpipe 
below  the  seat  of  obstruction. 

-  When  the  adhesions  take  place  between  the  vocal  cords,  the 
symptoms  are  very  serious,  there  being  dyspnoea  and  more  or 
less  complete  dysphonia,  or  even  aphonia,  if  the  condition  be  at 

all  extensive.     Operative  procedures  have  been  instituted  for 
24 


370        AFFECTIO]SrS    OF    THE    LARYISTX    AND    TRACHEA. 

the  relief  of  this  condition,  similar  to  those  employed  where  a 
bridge  of  tissue  stretches  from  one  cord  to  the  other  as  a  new 
growth,  or  as  a  result  of  the  inflammatory  action  follo\\'ing 
removal  of  a  neoplasm  from  this  situation,  as  detailed  under  the 
head  of  growths  in  the  larynx. 

An  interesting  case  of  this- kind,  in  which  external  section  of 
the  thyroid  cartilage  was  performed  in  order  to  divide  the  web, 
is  reported  by  Dr.  Morell  Mackenzie,'  and,  as  it  is  unique,  we 
copy  the  record  for  our  readers. 

"J.  D.,  aged  33,  formerly  a  farrier  in  the  Life  Guards,  was 
admitted  into  the  Hospital  for  Diseases  of  the  Tlu-oat,  May  11, 
1871,  wearing  a  canula.  Eighteen  months  previously  he  had 
been  admitted,  on  account  of  extreme  dyspnoea  and  complete 
aphonia,  which  had  existed  for  nearly  two  years,  and  was  due 
to  tertiary  syphilitic  disease  of  the  larynx.  Tracheotomy  had 
been  performed  at  the  time,  and  the  patient  left  after  a  few 
weeks,  wearing  the  tube. 

"  On  his  readmission,  an  examination  with  the  laryngoscope 
showed  a  web  extending  from  one  vocal  cord  to  the  other,  and 
occuj)ying  the  anterior  five-sixths  of  the  glottis.  He  was,  of 
course,  able  to  breathe  well  through  the  canula,  but  there  was 
absolute  loss  of  voice.  Under  these  circumstances,  it  was  deter- 
mined to  make  an  incision  in  the  mediate  line,  through  the 
thyroid  cartilage,  and  to  divide  the  web ;  and  in  order  that  it 
should  not  again  unite,  it  was  proposed  that  the  patient  should 
wear  a  double-branched  canula,  one  branch  consisting  of  the 
ordinary  tracheal  tube  passing  downwards,  and  a  second  similar 
tube  passing  upwards,  between  the  vocal  cords,  and  being- 
attached  externally  to  the  first  tube.  This  was  accordingly 
done  on  May  16.  The  patient  did  very  well  for  the  first  three 
days,  but  on  the  evening  of  the  third  day  it  was  seen  with  the 
laryngoscope  that  the  upper  portion  of  the  tube  was  producing 
an  ulcer  on  the  right  arytenoid  cartilage,  and  great  pain  was 
experienced  in  swallowing. 

"  On  the  following  morning.  May  20,  both  tubes  were 
removed,  as  it  was  deemed  important  to  allow  as  full  a  current 
of  air  as  possible  to  pass  through  the  trachea.  It  must,  how- 
1  Medical  Times  and  Gazette,  Aagust  19,  1871,  page  218. 


THE    CHEONIC    LARYNGITIS    OF    SYPHILIS.  371 

ever,  be  understood  that  tlie  upper  laryngeal  canula  was  obliged 
to  be  removed,  because  of  the  irritation  it  produced,  before  all 
cliances  of  reunion  were  over. 

"  He  appeared  perfectly  well  for  the  first  few  days,  but  on 
May  25,  one  or  two  severe  attacks  of  dyspnosa  having  occurred, 
the  tracheal  canula  was  replaced. 

"June  1. — On  laryngoscopic  examination,  it  was  found  that 
tlie  greater  portion  of  the  web  had  been  destroyed,  and  that 
more  than  three-fourths  of  the  area  of  the  glottis  was  free. 

"  The  man  is  now  acting  as  under-porter  at  the  Hospital,  and 
it  is  proposed  shortly  to  remove  the  tube.  At  present  he  is 
wearing  a  canula  with  a  pea- valve,  and  an  oval  opening  on  the 
upper  surface  of  the  tube." 

In  this  case  Dr.  Mackenzie  remarked,  "  that  he  had  pursued 
the  plan  of  treatment  which  he  had  found  successful  in  two 
previous  instances,  but  in  this  case  the  result  was  as  yet  only 
partially  successful.  Owing  to  the  adhesion  of  the  vocal  cords, 
the  man  had  been  completely  aphonic,  but  he  was  now  able 
to  speak  well.  At  the  time  that  it  was  originally  intended  to 
dispense  with  the  tracheal  tube,  there  was  a  good  deal  of  inflam- 
matory swelling  consequent  on  the  recent  operation,  and  hence 
the  patient  was  unable  to  breathe  without  an  artificial  opening. 
All  thickening  having  now  subsided,  there  is  every  reason  to 
believe  that  the  patient  will  soon  be  able  to  -breathe  perfectly 
well  through  the  natural  passages." 

As  a  result  of  chronic  laryngitis,  we  meet  not  unfrequently 
with  adhesions  of  various  parts,  which  sometimes  interfere  seri- 
ously with  the  due  performance  of  the  functions  of  deglutition,, 
phonation,  and  sometimes  even  of  respiration.  Without  going 
into  the  detail  of  the  various  examples  of  this  kind  which  may 
present  themselves,  we  may  mention  depression  of  the  ejDiglottis 
to  one  side  or  the  other,  preventing  proper  closure  or  complete 
erection  of  the  valve  ;  adhesions  of  the  ventricular  band  to  the 
vocal  cord  below,  preventing  j)roper  vibration  of  the  cord,  and 
thus  producing  often  a  shrill,  weak,  piping  voice,  and  sometimes- 
preventing  closure  of  the  glottis ;  adhesions  anteriorly  of  the 
two  vocal  cords,  or  of  the  two  ventricular  bands,  etc.     Besides. 


372        AFFECTIOIS-S    OF    THE    LARYIiX    ATS^D    TRACHEA. 

these  deformities,  we  have  others  the  result  of  cicatrization, 
some  of  which  are  alhided  to  elsewhere. 

The  treatment  of  these  conditions  consists  in  relieving  the 
constriction  as  far  as  possible  by  laryngoscopic  division  of  the 
adhesions,  and  then  cantei'izing  and  re-cauterizing  the  adjacent 
surfaces  to  prevent  fresh  adhesions.  These  cases  require  care- 
ful watching  and  promjJt  attention  to  prevent  recurrence,  which 
is  very  apt  to  take  place.  When  the  epiglottis  is  implicated, 
much  good  can  be  done  by  teaching  the  patient  to  move  the 
organ  frequently  during  the  day  by  means  of  his  forefinger. 

The   Treatment   of   Chronic    Laryngitis. — In  the  treat- 
ment of  chronic  laryngitis,  the  condition  of  system,  and  the  local 
manifestations   of   the  affection,  demand   equal  consideration. 
Cases  unattended  with   ulceration  of   the  mucous  membrane 
sometimes  yield  readily  to  simple  local  treatment,  by  mineral 
astringents,  with  due  attention  to  diet,  clothing,  exposure,  and 
maintenance  of  the  functions  of  the  skin  and  other  emunctories. 
The  local  remedies  may  be  inhaled  in  the  form  of  spray  in  weak 
solution,  or,  what  is  better,  may  be  applied  in  strong  solution 
directly  to  the  parts  by  the  laryngeal  douche,  or  by  the  brush  or 
sponge.      For  these  solutions  the  best   menstruum   is  water, 
though  some  physicians  prefer  glycerine  for  the  local  applica- 
tions by  the  mop.     For  inhalation  we  may  use  sulphate  of  zinc 
or  copper,  two  grains  and  upwards  to  the  ounce ;  the  acetate  of 
lead  in  similar  proportion  ;  the  sulphate  or  sesquichlorate  of 
iron  in  very  weak  solution  ;  carbolic  acid  a  grain  or  two  to  the 
ounce ;  the  nitrate  of  silver,  a  half  a  grain  and  upwards  to  the 
ounce  ;  or  the  nitrate  of  aluminium,  one  to  five  grains  to  the 
ounce.     These  and  similar  remedies  are  applicable  when  the 
secretion  is  in  excess.     Where  the  parts  are  dry,  we  may  employ 
solutions  of   muriate  of  ammonia,  five  grains  and  upwards  to 
the  ounce;  iodide  of  potassium  in  similar  proportion,  or  the 
compound  solution  of  iodine  and  iodide  of  potassium,  two  or 
three  drops  and   upwards  to  the  ounce  ;    chlorate  of  soda,  or 
chlorate  of  potassa,  five  grains  and  upwards  to  the  ounce  ;  or, 
what  I  have  often  found  excellent  in  inducing  secretions  of 
tlie  mucous  membranes  of   the  throat,  the  tincture  of  pyreth- 


THE    TEEATMENT    OF    CHROE^IC    LAEYJN-GITIS.  373 

rum,  or  the  Spanisli  pellitory  root,  from  ten  grains  and  upwards 
to  the  ounce.  To  these  inhahitions,  a  drop  or  two  of  good 
cologne-water  added  to  each  ounce  of  the  sohition,  will  render 
tlieir  contact  with  the  parts  much  more  grateful.  If  there  is  a 
good  deal  of  pain  in  the  parts,  small  cpantities  of  the  watery 
extracts  of  opium,  hjoscjamus,  belladonna,  stramonium,  and  the 
like  may  be  added.  Paregoric  is  often  an  excellent  article  for 
this  purpose. 

To  be  effective,  these  inhalations  should  be  taken  by  the 
patient  in  his  own  apartment,  about  three  times  a  day  ;  although 
in  the  cases  of  individuals  compelled  to  go  out  to  business  we 
may  prescribe  a  morning  and  evening  inhalation  only,  and  on 
this  account  may  increase  the  proportion  of  the  remedial  agent 
accordingly.  The  only  precautions  necessary  are,  to  avoid  irrita- 
tion of  the  bronchial  tubes  by  too  deep  inspirations,  when  strong 
astringents  are  used;  to  take  care  that  the  sprays  gain  access 
into  the  larynx ;  to  protect  the  face  and  teeth  from  nitrate  of 
silver,  preparations  of  iron,  etc.,  by  passing  the  sjDray  through 
a  funnel-shaped  glass  or  other  tube  passed  into  the  mouth  ;  and 
to  avoid  exposure  to  the  aii-  for  at  least  twenty  minutes  after 
having  taken  a  warm  inhalation. 

For  further  details  on  this  subject  the  reader  is  referred  to  the 
author's  volume  on  Inhalation,^  and  similar  works  of  the  kind. 

When  local  treatment  of  this  kind  is  ineflicient,  we  are  com- 
pelled to  resort  to  topical  medication  of  the  larynx  with  more 
.potent  remedies  ;  and  in  cases  of  long  standing,  or  of  much 
severity,  it  is  best  to  adopt  this  plan  at  the  commencement  of 
the  treatment.  At  the  same  time  appropriate  inhalations  may 
be  kept  up  by  the  patient  himself.  These  inhalations  serve  a 
better  purpose  than  the  gargles  which  were  formerly  emj)]oyed 
for  self -treatment. 

Of  all  the  local  remedies  employed  in  the  treatment  of 
chronic  laryngitis,  nitrate  of  silver  and  sulphate  of  zinc  will  be 
found  the  most  frequently  beneficial ;  but  where  the  laryngitis 
is  attendant  upon  tuberculosis,  tannin  w^ill  often  j)rove  more 
serviceable  ;  and  in  laryngitis   of   syphilitic  origin,    the    acid 

1  Inhalation  ;  its  Therapeutics  and  Practice.     Philadelphia^  1867. 


374      AFrECTiOjsrs  or  the  larynx  and  trachea. 

nitrate  of  mercury.  Iodine,  carbolic  acid,  nitrate  of  aluminium, 
chloride  of  gold,  chloride  of  zinc,  iodide  of  zinc,  the  various 
acids,  and,  in  fact,  the  entire  list  of  similar  destructive  chemicals 
prepared  in  the  laborator}-  have  been  extolled  for  the  topical  treat- 
ment of  chronic  laryngitis,  and,  ajopropriately  selected,  and 
carefully  applied,  are  no  doubt  beneficial.  In  some  individual 
cases  we  are  compelled  to  resort  to  an  unusual  remedy,  in  the 
hope  of  producing  an  effect  which  we  cannot  obtain  by  the 
means  ordinarily  employed.  The  materials  employed  by  the 
author,  for  topical  applications  to  the  larynx,  in  chronic  laryn- 
gitis, are,  almost  exclusively,  with  the  exception  of  special  cases 
referred  to  in  the  preceding  paragraph,  nitrate  of  silver  and 
sulphate  of  zinc  in  ordinary  cases,  tannin  in  cases  associated 
with  phthisis,  and  the  acid  nitrate  of  mercury  in  syphilitic  cases. 
The  laryngitis  attending  malignant  disease  is,  perhaps,  best  let 
aloiie,  as  far  as  severe  topical  applications  are  concerned,  unless 
it  becomes  necessary  to  interfere  for  the  restraint  of  hemorrhage  ; 
and  even  in  these  cases  the  bleeding  may  often  be  controlled  by 
inhalations  of  iron,  or  of  the  other  astringents  employed  in  the 
home  treatment  by  inhalation. 

The  author  has  acquired  the  habit  of  applying  nitrate  of 
silver  principally  by  the  sponge,  and  sulphate  of  zinc  almost  ex- 
clusively by  the  douche.  The  solution  of  nitrate  of  silver  varies 
from  forty  or  sixty  grains  to  the  ounce,  to  one  hundred  and 
twenty  grains,  and  in  some  cases  a  saturated  solution  is  em- 
ployed, usually  formed,  at  the  moment  of  use,  by  ruliljing  a  small 
bit  of  moistened  sponge,  for  some  seconds,  upon  a  large  crystal 
of  the  nitrate.  The  tolerance  of  the  parts  is  tested  by  a  weak 
solution  in  the  first  instance,  and  this  is  diminished  in  strength 
at  the  next  application,  or  increased,  according  to  the  behavior 
of  the  case.  He  deems  it  undoubtedly  better  when  the  appli- 
cation can  be  l^orne — and  it  can  be  borne  almost  always — to 
make  a  decided  impression  by  a  severe  application,  and  wait  three 
or  four  days  for  its  effects  to  subside  before  renewing  it,  rather 
than  to  torment  the  iirflamed  structures  by  the  daily  application 
of  mild,  and  too  often,  on  that  account,  inefhcient  solutions.  In 
some  cases,  the  solid  or  fused  nitrate  of  silver  is  employed,  but 
this  is  rarely  called  for  except  to  touch  an  isolated  spot,  and  to 


THE   TEEAT:MEXT   of   CHR0]S'IC  lakyi^gitis.  375 

prevent  tlie  nitrate  from  spreading  around  the  tissues  and  over 
tbem,  as  it  would  do  applied  in  solution  by  the  brush,  sponge, 
or  cotton  wad. 

The  sulphate  of  zinc  is  used  in  the  proportion  of  from  thirty 
to  sixty  grains  to  the  ounce.  I  emplo}"  it  princij)ally  in  cases 
where  there  is  o-eneral  cono-estion  of  the  entire  larvnx,  and  more 
or  less,  usually,  of  the  trachea  also.  Here,  the  use  of  the 
syringe,  or  the  douche,  enables  us  to  wash  the  parts  at  once  with 
a  stream  or  a  spray  of  the  solution. 

In  obstinate  cases  of  chronic  laryngitis,  persistent  counter- 
irritation  externally,  with  the  internal  use  of  iodide  of  potassium, 
arseniate  of  potassa,  muriate  of  ammonia,  the  bichloride  of  mer- 
cury, or  such  other  systemic  remedies  as  may  suggest  themselves 
from  the  peculiarities  of  the  case,  will  often  be  of  the  greatest 
service,  provided  the  strength  of  the  patient  can  be  maintained 
by  efficient  nourishment ;  otherwise  they  will  too  often  be  found 
absolutely  injurious.  Then  tonics,  such  as  quinine,  the  chloride 
of  iron,  should  be  employed  to  build  up  or  improve  the  system. 
The  skin  should  be  fi*equently  bathed,  excesses  at  the  table  pro- 
hibited, exposures  to  atmospheric  changes  avoided,  and  the  voice 
used  as  little  as  ma}"  be.  Where  the  patient  is  exposed  to  the 
inhalation  of  irritant  gases  or  vapors,  or  solid  particles  floating 
in  the  air,  he  should  wear  a  respirator  at  the  time,  or  cover  the 
nostrils  and  mouth  with  a  veil ;  or  keep  the  mouth  closed  and 
protect  the  nostrils  by  a  tiny  wad  of  cotton  wool,  delicate 
enough  not  to  interfere  with  respiration.  In  severe  cases,  at- 
tended with  frequent  cough,  the  respirator  or  its  substitute 
should  be  in  constant  requisition  to  modify  the  effect  of  the 
oxvgen  in  the  air,  which  is  sometimes  too  irritating  for  the  over- 
sensitive mucous  membrane.  The  value  of  the  respirator  in 
these  cases  cannot  be  appreciated  by  those  who  have  not  wit- 
nessed its  beneficial  effects  for  themselves.  Should  these  mea- 
sures fail  after  a  fair  trial,  we  must  be  content  to  adhere  to  a 
hvo'ienic  regimen,  and  to  resort  to  palliative  measures  as  occa- 
sion may  demand  them.  Where  the  patients  are  suitably  cir- 
cumstanced pecuniarily,  a  change  of  climate,  permanent  or 
temporary,  as  results  may  determine,  is  desirable.  Heroic  mea- 
sures will  not  be  likely  to  do  good,  and  may  transform  an  en- 


376         AFFECTIOIS^S    OF    THE    LARYNX   AND    TEACHEA. 

durable    condition   of    simple    chronic    inflammation    into   an 
ulcerative  one,  still  more  difficult  of  management. 

A  more  active  local  treatment  is  demanded  in  cases  of  ul- 
cerative laryngitis,  especially  when  connected  with  severe  in- 
flammation of  the  submucous  tissues,  and  attended  with  tume 
faction  of  the  epiglottis,  or  the  upper  boundaries  of  the  larynx, 
sometimes  amounting  to  oedema.  These  occur  chiefly  in  phthi- 
sis, sometimes  in  syphilis,  occasionally  in  simple  chronic  laryn- 
gitis. Here  local  treatment  is  required  not  so  much,  altogether, 
as  a  curative  agent,  but  as  the  best  means  of  affording  relief  to 
the  dysphagia  which  this  condition  entails,  and  which,  if  not 
allayed,  will  gradually  produce  death  by  starvation.  The 
best  material  for  this  local  medication  is  a  solution  of  nitrate 
of  silver,  sixty  grains  or  thereabouts,  to  the  ounce,  carefully 
applied,  every  other  day,  every  day,  or  even  twice  a  day,  as  the 
case  may  require.  Sometimes  applications  of  this  kind,  by 
coating  the  parts  with  a  protective  covering,  are  the  only  means 
of  aff"ording  the  patient  opportunities  to  swallow  his  nourishment. 

As  soon  as  the  condition  shows  unmistakable  signs  of  dimi- 
nution, these  applications  may  be  suspended  at  once.  Should 
the  condition  increase,  or  should  it,  at  the  onset,  be  of  such  a 
character  as  to  threaten  serious  symptoms,  scarification  should 
be  freely  employed,  as  described  in  connection  with  the  sub- 
ject of  oedema  of  the  larynx  ;  after  which  the  nitrate  of  silver 
may  be  employed,  should  it  seem  called  for.  When  the  con- 
dition is  under  subjection,  and  even  previously,  glycerine  swal- 
lowed if  possible,  or  applied  by  the  brush,  or  allowed  to  trickle 
along  the  back  of  the  throat,  will  often  be  of  service  ;  sometimes, 
indeed,  seeming  to  absorb  the  moisture  from  the  oedematous 
swelling,  and  thus  to  aid  in  its  reduction. 

The  difficulty  is  that  too  often,  this  condition  is  associated 
with  disease  of  the  cartilao-e,  and  recurs  again  and  again. 

Occasionally  the  chronic  laryngitis  is  confined  to  a  single 
structui-e,  as  the  .epiglottis.  Under  these  circumstances,  the 
complaint  is  often  rapidly  cured  by  local  treatment  alone,  as 
exemplified  in  the  following  record  of  a  case  of  epiglottitis  : 

A  lady,  set.  32,  applied  February  9,  1867,  to  l)e  treated  for  a 
sore  throat,  attended  with  painful  dysphagia  as  the  nioat  promi 


THE    TEEATMENT    OF    CHRONIC    LARYNGITIS.  377 

iient  symptom,  a  condition  which  had  existed  nearly  five 
months.  The  difficulty  of  swallowing  had  been  so  great  at 
times,  that  she  had  been  forced  to  assist  deglutition  with  her 
hands.  There  was  a  condition  of  chronic  follicular  pharyngitis, 
but  the  most  marked  appearance  of  disease  was  a  thickened  and 
inflamed  epiglottis,  relaxed  and  bent  backwards  towards  the 
right  side.  This  point  was  quite  painful  to  the  touch.  The 
parts  were  thoroughly  washed  with  a  solution  of  nitrate  of  silver, 
sixty  grains  to  the  ounce,  after  which  swallowing  was  accom- 
plished much  more  easily  and  without  pain.  Two  or  three  sub- 
sequent applications,  at  intervals  of  two  or  three  days,  relieved 
these  symptoms  entirely. 

The  treatment  of  chronic  laryngitis,  of  tuberculous  origin, 
would  vary  in  some  respects  from  that  already  described.  In 
the  first  place,  constitutional  treatment  is  of  paramount  impor- 
tance. The  hygienic  surroundings  of  the  patient  as  to  tem- 
perature, clothing,  diet,  occupation,  etc.,  should  be  the  very 
best  that  love  or  money  could  secure.  The  integrity  of  the 
digestive  organs  should  be  maintained,  to  the  exclusion  of  all 
other  treatment,  if  necessary.  The  most  nutritious  food  that 
can  be  digested  should  be  eaten,  including  the  taking  of  cod- 
liver  oil.  It  will  be  found  that  oftentimes  cod-liver  oil  is  best 
borne  about  three  hours  or  so  after  a  meal,  or  just  about  the 
close  of  stomachic  digestion.  If  necessary  it  may  be  alcoholized, 
etherized,  or  otherwise  made  palatable.  Sometimes  it  will  be 
found  to  be  taken  better  by  warming  the  tablespoon.  A  table- 
spoonful  morning  and  evening  is  usually  sufticient.  If  it  dis- 
agree with  the  patient,  or  cause  nausea  or  loss  of  appetite,  it 
must  be  abandoned.  Under  these  circumstances  the  pancreatic 
emulsion  may  be  employed.  I  have  used  it  a  great  deal,  and 
find  our  domestic  preparations  greatly  inferior  to  that  of  Messrs. 
Sav^ory  &  Moore,  of  London.  I  have  also  administered,  with 
great  advantage  in  these  cases,  as  an  additional  article  of  diet, 
the  extract  of  malt,  prepared  by  Linck,  of  Stuttgart.  I  have 
tried  several  domestic  preparations  of  malt  extract,  as  well  as 
others  from  other  sources,  and  find  none  of  them  equal  to  that 
of  Linck.     It  is  in  a  thick  paste,  somewhat  like  guava  jelly, 


378         AFFECTIOjsrS    OF   THE    LAETNX   AIS'D    TRACHEA. 

and  can  be  eaten  from  the  sj)Oon,  or  be  spread  on  bread,  or  be 
dissoh'ed  in  water  or  milk.  A  table-spoonful  stirred  into  balf 
a  j^int  of  milk  makes  a  chocolate-colored  mixture  that  is  readily 
taken.  One  or  two  ounces  of  this  extract  of  maU  may  be  taken 
daily,  or  twice  a  day.  It  is  not  a  beer;  but  a  pure  extract  of 
the  malt  which  has  not  been  allowed  to  undergo  fermentation. 

Quinine  is  often  administered  as  a  tonic,  and  the  usual  prac- 
tice of  the  profession  is  to  associate  iron  with  it,  though  I  gen- 
erally depend  upon  the  quinine  alone,  and  try  to  get  iron  in 
with  the  food. 

The  constitutional  treatment  would  therefore  be  exactly  that 
for  tuberculosis  of  the  lungs. 

Local  treatment  is  also  requisite  in  this  form  of  laryngitis. 
It  is  not  always  curative  by  any  means  ;  but  it  is  almost  always 
indispensable  as  a  means  of  relief. 

Nitrate  of  silver  does  good  ser%dce  in  this  form  of  laryngitis  ; 
but  in  some  instances  tannin  seems  more  useful.  I  emj^loj^  a 
saturated  solution  of  tamiin  in  glycerine,  two  drachms  to  the 
ounce,  and  apply  it  by  the  sponge,  cotton  wad,  or  the  pencil,  as 
may  seem  most  desirable.  Sometimes  the  powder  of  tannin  is 
propelled  over  the  parts,  sometimes  it  is  applied  by  the  sponge. 
Solutions  of  it  in  water,  too,  are  often  used. 

As  an  inhalation,  I  often  prescribe  the  spray  of  tepid  water, 
containing  a  drop  or  two  of  Eau  de  Cologne  to  the  ounce. 
This  is  grateful  to  the  parts,  and  assists  the  dislodgment  of  the 
products  of  secretion.  Where  the  secretion  is  abundant  and 
tenacious,  excellent  results  often  follow  the  inhalation  of  solu- 
tions of  the  carbonates  of  soda  or  potassa ;  where  it  is  excessive 
or  unpleasant  in  odor,  much  benefit  follows  the  use  of  carbolic 
acid,  a  grain  or  two  to  the  ounce,  to  which  may  often  be 
added  a  few  drops  of  the  compound  solution  of  iodine.  In 
a  few  instances  I  have  seen  this  combination  work  wonders, 
and  apparently  arrest  the  onward  march  of  confirmed  phthisis 
with  ulcerative  laryngitis,  and  permit  the  resumption  of  the  pa- 
tient's ordinary  employments,  where  no  such  effect  had  been 
expected.  In  other  respects  the  local  treatment  would  be  that 
for  chronic  laryngitis  in  general. 

Fresh  air  and  an  equable  temperature  is  to  be  maintained. 


THE    TEEATMENT    OF    CHROIN'IC    LARYJSTGITIS.  379 

The  patient  should  be  encouraged  to  go  out  every  day  for  two 
or  tliree  hours  at  least,  and  when  at  home  should  occupy  a  room 
kept  at  a  temperature  of  at  least  70°  F.,  as  ascertained  by  the 
thermometer,  care  being  taken  to  keep  the  aii-  from  becoming  too 
dry,  and  to  maintain  ventilation  by  means  of  an  open  window, 
without  exposing  the  patient  to  its  direct  draught. 

Too  often,  alas,  we  are  unable  to  restrain  the  march  of  the 
disease  to  its  fatal  termination,  when  all  that  we  can  do  is  to  be 
guided  in  our  actions  by  the  progressive  needs  of  the  case,  and 
to  soothe  the  path  to  the  grave  by  every  means  in  our  power. 

Tracheotomy  has  been  recommended  in  cases  of  the  kind 
under  discussion,  for  the  purpose  of  securing  rest  to  the  inflamed 
larynx;  and  the  operation  has  sometimes  been  performed  with 
such  a  result.  It  cannot  be  curative  however,  directly  or  in- 
directly, and  therefore  should  be  resorted  to  only  in  cases  where, 
from  oedema  or  the  impaction  of  necrosed  cartilage,  asphyxia 
was  threatened. 

The  treatment  of  syphilitic  laryngitis,  in  its  primary  catarrhal 
or  secondary  ulcerati\"e  manifestations,  would  not  differ  from 
that  of  ordinary  laryngitis,  except  that  in  secondary  ulcerations, 
if  there  were  no  signs  of  retrogression,  the  patient  would  be 
mercurialized.  In  the  tertiary  forms  of  syphilis,  however,  be- 
fore the  disease  has  progressed  to  irreparable  destruction,  it  can 
almost  always  be  promptly  arrested  by  the  internal  nse  of  the 
iodide  of  potassium  and  the  bichloride  of  mercury,  and  the  local 
application  of  acid  nitrate  of  mercury  to  the  diseased  structures. 
The  caustic  may  be  of  the  strength  of  one  part  in  from  four  to  ten 
of  water,  and  may  be  applied  every  second  or  third  day.  Strong 
nitrate  of  silver,  and  the  acids,  are  also  efhcient ;  but  not  more  so 
than  the  acid  nitrate  of  mercury,  and  often  much  less  so.  ^Yhen 
syphilitic  laryngitis  has  existed  for  a  longtime,  such  destruction 
has  taken  place  and  such  poisoning  of  the  system  as  to  render  a 
cure  impossible.  The  constrictions  of  the  parts  produced  by 
the  cicatrices  of  extensive  ulcers,  and  the  adhesions  between 
adjoining  surfaces,  is  often  such  as  to  render  tracheotomy  ne- 
cessary, with  the  permanent  use  of  the  tube ;  for  the  constric- 
tions following  syphilis  are,  as  a  rule,  inamenable  to  dilatation. 


380        AFFECTIONS    OF   THE    LAKYJSTX   AND    TEA  CHE  A. 

MANIPULATIONS    WITHIN    THE   LARYNX. 

It  is  hardly  necessary  to  say  that  the  topical  treatment  of  all 
intra-laryngeal  affections  should  be  carried  on  nnder  the  guid- 
ance of  the  laryngoscope.  It  will  be  well,  therefore,  to  de 
scribe  the  method  of  making  these  applications,  and  the  in- 
struments suitable  for  the  purpose  ;  with  which  view  the  author 
reproduces  in  part  some  remarks  appearing  originally  else- 
where.' Certain  general  manipulations  are  necessary  for  the 
proper  introduction  of  every  instrument  within  the  larynx,  from 
a  blunt  probe  to  an  exposed  bistoury.  Practice  is  necessary  to 
learn  to  follow  the  reflex  of  the  instrument  in  the  laryngeal 
mirror.  The  plan  which  the  writer  has  found  most  useful  in 
instructing  his  pupils,  is  to  have  them  begin  by  holding  the 
laryngeal  mirror  over  a  plane  surface,  as  for  instance,  the  page 
before  us,  the  paper  representing  the  plane  of  the  upper  sur- 
face of  the  larynx,  and  the  mirror  being  held  an  inch  or  more 
above  it,  at  an  inclination  of  about  50°.  For  this  purpose  a 
laryngeal  picture,  such  as  the  drawing  on  page  19,  fig.  9,  maybe 
advantageously  employed.  The  student  is  directed  to  take  a 
j^robe  in  his  other  hand,  and,  keeping  his  vision  upon  the  image 
in  the  mirror  of  the  spot  he  designs  touching,  to  carry  the  probe 
towards  the  mirror  until  it  is  nearly  in  contact,  and  to  move  the 
probe  gently  until  a  distinct  view  is  obtained  of  the  image  of 
its  point ;  when,  without  losing  siglit  of  the  image  of  the  end 
of  the  probe,  it  is  to  be  directed  towards  the  selected  spot,  and 
to  be  slowly  carried  to  it.  A  little  practice  soon  renders  one 
familiar  with  the  degree  of  inclination  necessary  to  be  given  to 
the  probe  to  secure  the  desired  movement.  After  this  pro- 
cedure has  been  repeated  often  enough  to  familiarize  the  stu- 
dent with  the  proper  method  of  following  the  reflex  of  his 
manipulations,  so  as  to  carry  his  instrument  at  will  to  the  right 
or  the  left,  the  front  or  the  rear,  the  straight  probe  is  exchanged 
for  a  curved  one,  such  as  would  be  suitable  for  introduction  into 
the  larynx,  and  then  the  same  exercises  are  repeated ;  a  second 
person,  after  a  while,  designating  the  points  which  the  student 
is  to  endeavor  to  touch.     A  three-sided  tube  of  pasteboard,  of 

'  The  Medical  Bec&rd^  Sept.  1,  1867. 


MAlN-IPULATIOlSrS    WITHIN    THE    LARYIS'X. 


381 


the  size  of  the  larynx,  with  certain  marks  npon  its  inner  sur- 
faces is  then  snbstitntecl  for  the  sheet  of  paper,  printed  I3age,  or 
laryngeal  picture,  and  the  mirror  is  then  held  above  this  so  as  to 
reflect  the  image  of  its  interior ;  and  the  exercises  are  repeated. 
The  difficulty  of  reaching  a  desired  spot  is  now  rather  greater 
than  before,  and  this  compels  the  student  to  learn  to  raise  the 
handle  of  his  iustrnment  if  he  wishes  to  touch  the  anterior  sur- 
face of  the  tube,  and  to  depress  it  in  order  to  carry  the  point  of 
his  instrument  towards  the  posterior  portion  of  the  tube,  as  also 
the  proper  movements  to  the  one  side  or  the  other. 

Fig.  64. 


Monnted  skull  for  preliminary  practice  in  the  operative  procedures  of  intra-larj'ngeal  surgery 
(after  Tobold).    A  perforated  tracheotomy-tube,  with  tracheal  mirror,  is  inserted  into  the  trachea. 

After  this  a  papier-mache  model  of  a  larynx  is  employed  as 
a  means  of  exercise ;  and  finally,  the  method  introduced  by 
Tobold,  which  is,  to  mount  a  recently  excised  lai-ynx  with  the 
tongue,  soft  palate,  etc.,  upon  the  rod  supporting  a  mounted 


382     affectiojN's  of  the  larynx  and  trachea. 

skull  with  tlie  jaws  separated ;  the  oesophagus  being  tied  around 
the  rod.  Where  a  recent  human  larynx  cannot  be  obtained,  a 
wet  preparation  or  a  dried  one,  an  artificial  one  or  one  from 
one  of  the  inferior  animals,  is  substituted. 

After  a  certain  amount  of  facility  has  been  acquired  in  this 
way,  it  is  necessary  to  learn  how  to  manage  the  mirror  and 
operating  instrument  with  artificial  light.  This  is  best  done  by 
suspending  the  model  or  mounted  skull  within  a  box  having  a 
small  opening  to  represent  the  mouth  in  its  relative  position  ; 
and  then  the  light  is  to  be  thrown  in  upon  the  parts,  and  the 
manipulation  proceeded  with  as  before. 

Even  after  all  this  preliminary  practice,  it  will  recpiire  a  great 
deal  of  patience  to  learn  to  use  instruments  upon  a  patient 
in  whom  nervousness,  and  the  natural  irritability  of  the  struc- 
tures, will  cause  more  or  less  movement  of  the  parts,  whose 
reflex  must  be  followed  promptly  and  accurately  in  order  to 
insure  precision  of  application.  This  is  especially  necessary 
when  the  desired  application  is  to  be  limited  to  a  small  area  of 
diseased  structure. 

The  princijjal  rule  to  be  observed  in  all  these  manipulations, 
be  they  what  they  may,  is  : 

To  carry  the  instrument  well  towards  the  mirror,  until  its 
point  is  visible  in  the  image,  and  not  to  lose  sight  of  the  point 
during  the  operation. 

Frequently,  the  instrument  will  have  to  be  withdrawn  again 
and  again  before  a  favorable  opportunity  is  presented  for  carry- 
ing it  home ;  but  with  increased  practice,  the  expert  soon  be- 
comes able  to  succeed  at  almost  every  attempt. 

We  can,  in  this  way,  not  only  make  local  applications  of  a 
general  nature,  such  as  swabbing,  syringing,  etc.,  but  we  can 
cauterize  circumscribed  ulcers ;  open  abscesses ;  ligate,  excise, 
twist  off,  or  crush  up  tumors ;  scarify  granulations  and  tume- 
factions ;  electrize  individual  muscles ;  in  fact,  perform  almost 
every  surgical  operation  not  necessitating  dissection ;  and  this, 
without  compromising  the  integrity  of  the  healthy  structures  in 
the  neighborhood  of  the  operation. 

The  instrument  which  is  to  be  carried  into  the  larynx  must 
be  constructed  with  a  suitable  curve  or  ano-le.     The  ansde  most 


MANIPULATIONS    WITHIN    THE    LAEYNX.  3S8 

generally  serviceable  is  one  of  perhaps  112°,  but  if  it  be  a 
little  greater  or  a  little  less,  it  will  make  no  material  difference 
in  most  cases.  The  angular  instrument  will  occupy  more  room 
in  the  pharynx,  but,  in  certain  instances,  is  advantageous  by  the 
room  it  gives  to  avoid  touching  the  epiglottis  unnecessarily. 
The  laryngeal  portion  of  the  instrument  may  vary  from  an  inch 
and  a  half  to  three  inches  in  length,  and  the  handle  or  stem  from 
six  to  eight  inches.  Under  certain  circnmstances  the  usual  form 
of  the  instrument  may  be  conveniently  departed  from  in  conse- 
quence of  peculiar  conformation  of  the  larnyx,  or  where  it  is 
intended  to  operate  upon  the  anterior  or  the  posterior  portion 
of  the  tube.  In  the  former  instance  the  angle  may  be  more 
acute,  and  in  the  latter  more  obtuse ;  otherwise,  the  necessary 
depression  or  elevation  of  the  hand  to  reach  the  desired  spot, 
will  exact  unusual  skill  on  the  part  of  the  operator. 

The  management  of  the  head  and  tongue  of  the  patient  had 
better  be  left  to  himself.  If  he  is  a  little  nervous  his  head 
may  rest  upon  the  breast  of  a  friend,  or  against  a  special  head- 
rest similar  to  that  used  in  photography. 

When  the  tongue  is  fleshy  or  very  unruly,  a  tongue-depressor 
may  be  necessary  to  control  it. 

Light,  patient,  tongue,  etc.,  being  in  proper  adjustment,  the 
operator  introduces  the  mirror  with  one  hand,  while  Avith  the 
other  he  takes  up  the  operating  instrument  and  passes  it  well 
back  into  the  pharynx  and  close  to  the  mirror,  carefully  avoid- 
ing contact  with  any  of  the  structures ;  then,  with  the  image  of 
the  laryngeal  mirror,  as  the  "  guide  to  the  operating  hand,"  the 
point  of  the  instrument  is  to  be  directed  towards  the  desired 
spot,  and,  following  the  reflection,  is  to  be  carried  there  prompt- 
ly and  quietl}^  The  instrument  must  be  taken  in  hand  as  if 
it  were  a  pen, — not  as  if  it  were  a  cart- whip,  a  position  in 
which  too  many  are  apt  to  hold  it, — and  the  fingers  being  ex- 
tended on  the  wrist,  the  laryngeal  portion  is  to  be  carried  over 
the  tongue,  until  its  approach  is  seen  in  the  mirror.  Instru- 
ments for  special  purposes  are  provided  with  rings  and  buttons 
for  the  thumb  and  fingers.  It  is  not  always,  even  after  long 
practice,  that  the  actual  contact  of  instrument  with  the  diseased 
spot  can  be  recognized  in  the  mirror,  for  usually,  and  nearly 


384         AFFECTIOIS^S    OF    THE    LARYNX    AISTD    TRACHEA. 

always  at  a  first  application,  spasmodic  action  ensues  at  the 
moment  of  contact ;  and  sometimes  the  instrument,  if  not  with- 
drawn, will  be  caught  upon  the  epiglottis  or  upon  tlie  base  of 
the  tongue ;  an  occurrence  which  it  is  desirable  to  be  able  to 
avoid  ;  although  under  certain  circumstances,  as  when  a  general 
application  is  being  made  by  means  of  a  moistened  sponge,  the 
action  may  be  advantageous  by  compressing  the  sponge  and 
thus  forcing  its  contents  out  upon  the  parts.  Under  these  cir- 
cumstances the  character  of  the  contact  is  to  be  determined  by 
the  impression  conveyed  to  the  finger  by  the  end  of  the  instru- 
ment. As  soon  as  practicable  after  the  operation,  which  means 
as  soon  as  the  spasmodic  action  it  excites  ceases,  the  parts  are 
to  be  examined  in  the  usual  manner,  in  order  to  judge  of  the 
success  of  the  application  or  the  necessity  for  its  repetition. 

Patients  soon  become  accustomed  to  the  momentary  contact 
of  a  foreign  body  against  the  laryngeal  mucous  membrane  ; 
but  at  the  earlier  applications  the  distress  is  often  very  great 
indeed.  There  is  a  great  deal  of  spasm  with  choking  sensa- 
tions, and  expectoration,  at  times  associated  with  cough ; 
while  the  sense  of  constriction  and  dread  of  suffocation  some- 
times endures  for  se\eral  minutes.  The  same  sensitive  effect 
occurs  as  when  a  foreign  body  has  been  removed  from  the 
conjunctival  mucous  membrane,  in  the  continuance  of  the 
sensation  its  presence  produced.  From  a  similar  cause  patients 
will  continue  to  feel  as  if  the  sponge  were  in  the  throat 
after  it  has  been  withdrawn,  and  this  will  sometimes  keep 
up  the  feeling  of  impending  suffocation,  though  sometimes 
there  will  be  actual  spasm,  so  that  all  the  distressing  symp- 
toms of  strangulation  will  be  presented.  A  few  forced  ex- 
pirations, or  the  inhalation  of  a  whiff  or  two  of  chloroform, 
will  soon  control  the  spasm  if  it  does  not  subside  promptly. 
With  each  repetition  of  the  application,  however,  the  sensibil- 
ity of  the  parts  decreases,  until,  after  a  while,  the  operation 
will  be  followed  by  a  mere  hawking  or  clearing  of  the  throat. 
In  the  earlier  applications,  too,  the  effect  will  be  to  induce  ac- 
tive congestion  of  the  parts,  with  increased  secretion  followed 
b}''  a  seiise  of  rawness,  dryness,  or  burning,  in  greater  or  less 
degree,  and  continuing  for  a  period  varying  from  fifteen  min- 


MAIv^IPULATIOISrS    WITHIlSr    THE    LAEYNX.  385 

ntes  to  several  hours.  As  the  applications  are  repeated  these 
effects,  too,  gradually  diminish  in  intensity.  The  swallowing 
of  cold  water  will  materially  alleviate  this  distress  when  it  is 
severe ;  and  if  it  continues  for  some  time  the  inhalation  of  an 
anodyne  solution  or  vapor  will  overcome  the  irritation. 

Very  often  a  successful  application  or  operation  can  be  made 
at  the  first  attempt ;  but  in  all  cases  of  extreme  irritability  of 
structures  a  certain  amount  of  preparatory  manipulation  is 
necessary.  The  best  method  of  inducing  tolerance  of  manipu- 
lation is  by  the  repeated  contact  of  an  extraneous  body.  We 
may  instruct  the  patient  how  to  pass  an  instrument  into  his  own 
larynx,  a  probang  armed  wdth  a  small  sponge,  for  instance,  and 
direct  him  to  insert  it  two  or  three  times  a  day  until  the  con- 
tact of  the  instrument  can  be  endured  without  flinching.  This 
practice  may  be  at  times  necessary  anterior  to  the  employment  of 
cutting  instruments  or  forceps  in  the  removal  of  growths,  etc. ;  less 
so  when  cauterization  or  general  applications  are  to  be  instituted. 

Very  often  the  epiglottis  is  more  irritable  than  the  interior 
of  the  larynx,  and  to  overcome  this  the  best  plan  is  for  the 
operator  to  pass  his  fiuger  behind  the  patient's  epiglottis,  and 
pull  it  forward  several  times,  and  then  to  teach  the  patient  how 
to  perform  the  manoeuvre  himself,  and  direct  him  to  rejjeat  it 
occasionally,  at  intervals  during  the  day.  Then  he  may  be  pro- 
vided with  an  extension  thimble,  with  a  good,  broad,  blunt  end, 
and  insert  that  several  times  a  day.  When  the  epiglottis  is. 
very  much  depressed,  the  patient  must  pull  it  forward  frequent- 
ly, so  as  to  induce  it  to  assume  a  more  erect  position.  A  pa- 
tient can  be  taught  to  raise  the  epiglottis  with  one  forefinger, 
and  then  to  pass  a  sponge  probang  along  the  back  of  the  finger 
down  into  the  larynx.  By  this,  or  some  similar  method,  the 
sensibility  of  the  part  will  be  gradually  subdued  ;  and  it  is  sur- 
prising sometimes  how  soon  the  irritability  is  overcome.  Andl 
here  we  are  led  to  make  an  important  practical  observation,^ 
which  is,  that  a  patient  who  has  been  suffering  a  long  time  with, 
severe  disease,  even  when  of  nervous  temperament,  will  learn  tO/ 
control  his  sensations  promptly,  while  one  whose  trouble  is  trivial 
or  imaginary,  wall  require  longer  tuition  and  preliminary  mani- 
pulation. Again,  it  will  be  noticed,  that  a  patient  who  may  be.- 
25 


386       AFFECTIOI^S    OF     TIIE    LARYjS"X   AIS^D    TEACIIEA. 

exceedingly  docile,  and  raay  co-operate  ^rell  witli  liis  physician 
during  the  earlier  interviews,  will  sometimes  become  less  toler- 
ant of  manipulation  as  relief  is  being  obtained. 

Where  obstinate  depression  of  the  epiglottis  precludes  the 
convenient  introduction  of  an  instrument,  it  will  have  to  be 
forcibly  raised  by  means  of  properly  curved  forceps,  hooks,  or 
pincettes,  of  which  that  of  Yon  Bruns  is,  perhaps,  the  best. 

Certain  precautions  are  necessary  to  success  in  limiting  a 
local  ajDplication  to  certain  portions  of  structures,  and  in  order 
to  gain  access  to  others ;  and  for  this  purpose  we  avail  ourselves 
of  the  physiological  effect  of  voluntary  movement.  Thus,  if 
we  want  to  medicate  the  floor  of  the  glottis,  or  prevent  any  of 
the  material  used  fi-om  entering  the  trachea  and  lower  laryngeal 
cavity,  we  direct  the  patient  to  emit  a  vocal  sound,  which  of 
course  closes  the  glottis ;  if,  on  the  contrary,  we  desire  the  in- 
strument to  enter  the  lower  laryngeal  cavity,  or  penetrate  into 
the  trachea,  we  direct  a  deep  inspiration  to  be  taken  which 
opens  the  glottis  and  permits  the  passage  of  the  instrument  be- 
tween its  lips  ;  if  we  wish  to  make  an  application  to  the  laryn- 
geal surface  of  the  epiglottis,  or  to  the  anterior  portion  of  the 
vocal  cords,  ventricular  bands,  etc.,  we  direct  the  forcible  ex- 
tension of  the  tongue,  and  the  utterance  of  a  note  of  high  pitch, 
or  an  ironical  laugh,  in  order  to  expose  these  structures  more  fully ; 
if  we  wish  to  touch  a  spot  upon  the  lingual  face  of  the  epiglot- 

Fig.  65.      9 


Laryngeal  brush  and  sponge-holder. 

tis,  or  in  the  glotto-epiglottic  sinuses,  or  upon  the  base  of  the 
tono-ue,  we  allow  the  base  of  the  tongue  to  remain  in  a  more 
natural  position,  or  cause  it  to  be  protruded  in  such  a  way  as 
will  not  raise  the  epiglottis  to  its  erect  position,  etc.  Then, 
ao-ain,  the  preliminary  movements  of  retching,  swallowing, 
couo-hinp",  etc.,  voluntarily  executed,  will  raise  the  entire  larynx, 
and  bring  the  structures  within  nearer  reach  of  an  instrument. 
The  accompanying   illustrations,  Figs.   65,  66,  67,  6S,  69,  70, 


MATHPULATIOIS^S    WITHIlSr    THE   LAETNX.  387 

exhibit  at  a  glance  the  form  of  instruments  most  convenient 


Fig.  66. 


Tiirck's  laryngeal  brush. 


Pig.  68. 


Pig.  67. 


r 


Tobold's  laryngeal  syringe.        Gibb's  laryngeal  douche. 


for  making  topical  applications  to  the  larynx  in  the  treatment 
of  laryngitis  and  other  affections. 


388       AFFECTIOlSrS    OF    THE    LARYIS^X    AND    TRACHEA. 


Fig.  67  represents  a  yerj  couyenient  syringe,  the  nozzle  of 
wliicli  is  of  liard  rubber,  with  a  silver  tip  pierced  with  several 
fine  holes,  to  j)ermit  of  the  better  distribution  of  the  fluid.  The 
barrel  is  of  glass,  and  the  piston-rod,  if  desired,  can  be  gradu- 
ated, so  as  to  secure  accuracy,  if  deemed  important.  The 
rings  on  the  barrel  are  for  the  first  and  second  fingers  ;  the  ring 
on  the  piston-rod  for  the  thumb.  Its  manner  of  employment 
is  obvious. 

For  projecting  a  finely  divided  douche  into  the  larynx  in  the 
form  of  a  spray,  which  shall  irritate  the  parts  less  than  an  in- 
jection from  a  syringe,  the  best  instrument  which  has  been  de- 
vised is  the  laryngeal  douche  of  Dr.  Gibb,  of  London  (Fig.  68). 

Fig.  69. 


Newman's  spray-prodiicer. 


It  consists  of  a  silver  tube,  to  the  free  extremity  of  which  there 
is  screwed  on  a  platinum  bulb,  perforated  by  a  number  of  ex- 
ceedingly minute  openings.  The  other  extremity  of  the  tube  is 
fastened  within  the  neck  of  a  rubber  ball.  The  instrument  is 
charged  by  dipping  the  bulb  into  the  solution  while  the  ball  is 
compressed,  and  then  releasing  the  ball.  It  is  discharged  by 
compressing  the  extremity  of  the  ball  with  the  thumb,  while 
the  tube  is  held  between  the  first  and  second  fingers. 

The  spray-producer,  (Fig.  69)  devised  by  Dr.  Robert  Xewman, 


MAJSriPULATIONS    WITIIUST    THE    LAEYNX.  889 

of  'New  York,  is  constructed  on  the  principle  of  one  capillary 
tube  inclosino;  another.  The  double  air-chamber  of  the  rubber 
tube  presses  the  air  through  the  inner  tube  r  r,  and  directs  the 
spray.  The  same  movement  exhausts  the  air  from  the  outer 
tube  ^ p.  As  soon  as  there  is  a  vacuum  in  the  outer  tube,  the  fluid 
from  the  vial  S  is  forced  upwards  into  it,  and  surrounds  the 
inner  tube.  The  continued  j^ressure  forces  the  fluid  through  the 
small  opening,  and  produces  the  spray.  The  fluid  is  carried  in 
the  outer  tube — the  air,  which  makes  the  spray  in  the  inner  tube. 
The  opposite  mechanism — i.e.,  the  inner  tube  carrying  the  fluid, 
and  the  outer  the  air,  will  produce  the  same  effect.  Instruments 
constructed  according  to  the  latter  theory  have  been  made  by  the 
same  artist,  and  work  well.  These  nebulizers  are  made  to  direct 
the  spray  in  different  ways :  upwards,  downwards,  or  straight 
forward.  Either  of  these  directions  is  produced  by  the  end  of 
the  inner  tube,  which  conveys  tlie  air.  But  in  either  case  the 
instrument  is  only  one  piece  of  machinery.  Fig.  1  represents 
the  straight  nebulizer  in  operation  ;  pj>p  is,  the  outer  tube  ;  r  r 
inner  tube.     S  the  vial  witli  the  medicated  fluid. 

Fio;.  2  is  the  end  of  a  nebulizer  turned  downwards  for  the 
larynx,  etc.,  and  Fig.  3  the  end  of  another  which  sprays  upwards 
for  the  posterior  nares. 

These  instruments  possess  many  advantages.  They  are  clean 
and  do  not  decompose  the  solutions ;  produce  a  fine  spray; 
never  need  repairs,  and  are  easily  kept  in  order.  They  are  not 
patented.     Hence,  they  are  strongly  recommended. 


Fig.  70. 


Kauchfuss'  laryngeal  powder-insufflator. 

For  projecting  powders  into  the  larynx,  the  insufflator  of 
Rauchfuss  (Fig.  70)  is  admirably  adapted.  The  powder  is  in- 
serted into  a  slot,  which  is  then  covered  by  a  slide.  The  instru- 
ment is  then  discharged  in  the  same  manner  as  Gibb's  douche. 


390      AFFECTIONS    OF   THE    LAEYjSTX   AND    TRACHEA. 

The  employment  of  powders  for  purposes  of  general  medica- 
tion of  the  larynx  will  sometimes  be  found  much  less  irritating 
than  the  use  of  solutions.  These  powders  must  be  properly 
diluted  with  some  innocuous  material. 

ELEPHANTIASIS    OF    THE   LARYNX. 

There  is  no  doubt  that  the  larynx  is  peculiarly  affected  in 
elephantiasis,  but  the  accounts  given  of  the  condition  are  too 
meagre  and  conflicting  to  admit  of  any  satisfactory  analysis. 
There  appears  to  be  more  or  less  catarrhal  inflammation,  with 
hypertrophy  of  some  portions  of  the  laryngeal  structures,  and 
destruction  of  tissue  in  others.  Gibb '  speaks  of  a  peculiar 
shrillness  of  the  voice,  the  production  of  which  hardly  appears 
to  be  accounted  for  in  his  description  of  the  affection.  Wolff,'' 
who  has  examined  a  number  of  cases  in  the  island  of  Madeira, 
does  not  mention  this  peculiarity  of  voice.  lie  sj)eaks  of  a 
fatal  constriction  of  the  larynx,  and  also  of  oedema  rapidly  fatal ; 
a  condition  which  ISTorwegian  physicians '  have  often  encoun- 
tered. This  affection  is  usually  connected  with  a  similar  con- 
dition of  tongue  and  pharynx,  and,  according  to  the  belief  of 
Mackenzie,^  never  attacks  the  mucous  membrane  until  after  it 
has  manifested  itself  upon  the  cutaneous  surface. 

INFLAISQIATIONS    OF    THE    TKACHEA. 

The  trachea  is  liable  to  inflammation  and  its  products,  and 
frequently  participates  in  the  diseases  affecting  the  larynx. 
Occasionally,  however,  the  disease  is  confined  to  the  windpipe. 

Acute  inflammation  of  the  trachea  occurs  sometimes  as  an 
idiopathic  affection,  sometimes  as  a  symptom  of  small-pox, 
measles,  typhus,  pulmonary  tuberculosis,  croup,  etc.  Pain 
referred  to  the  windpipe  and  to  the  top  of  the  sternum,  an 
expectoration  of  mucus,  sometimes  in  regular  rings,  and  the 
accompaniment  of  a  peculiar  brazen-like  cough,  are  the  main 

'  On  the  Throat  and  Windpipe,  p.  273. 

'  De  Lepra  Arabum  (Elephantiasis  GrEecorum).  Virchow's  ArcMv,  1863, 
Bd.  26. 

*Turck,  op.  cit.  p.  429. 

*  On  Growths  in  the  Larynx,  p.  36. 


USTFLAMMATIONS    OF    THE    TEACHEA.  391 

feattires  of  differential  diagnosis,  from  laryngitis  bronchitis,  or 
general  catarrhal  iniiammation  of  the  air-]Dassages.  If  the 
disease  is  confined  to  the  trachea,  there  will  be  no  hoarseness. 
In  favorable  cases,  the  parts  can  be  examined  with  the  laryngo- 
scope. The  mucous  membrane  covering  the  rings  and  inter-car- 
tilaginous spaces,  will  be  more  or  less  red  or  dark  red  in  color; 
but  this  apjDearance  is  not  to  be  depended  on  as  a  certainty  in 
diagnosis. 

Chronic  inflammation  of  the  trachea  accompanies  follicular 
pharyngo-laryngitis,  pulmonary  tuberculosis,  and  syphilis.  The 
mucous  membrane  is  dark  red,  as  seen  on  laryngoscopic  inspec- 
tion, and  clumps  of  mucus  are  usually  adherent,  here  and  there, 
to  the  cartilages  or  interspaces.  Though  usually  associated  with 
chronic  laryngitis,  this  affection  is  sometimes  met  with  alone. 
The  chronic  inflammation  accompanying  tuberculosis  and  syphi- 
lis is  apt  to  extend  itself  to  the  submucous  tissues,  in  some 
instances  to  invade  the  cartilaginous  structures,  producing 
extensive  and  irremediable  destruction  of  tissue,  of  which,  as  a 
rule,  no  adequate  conception  can  be  obtained,  even  by  the  use 
of  the  laryngoscope,  until  an  examination  of  the  parts  after  the 
death  of  the  patient.  Papillomatous  vegetations  similar  to 
those  produced  in  the  analogous  ulcerations  of  the  larynx  are 
occasionally  met  with. 

Syphilitic  ulcerations,  in  addition,  and  sometimes  tuberculous 
ones,  are  apt  to  be  accompanied  in  their  cicatrization  by  a  con- 
traction sometimes  amounting  to  stricture,  a  condition  usually 
irremediable  if  below  the  point  at  which  a  tracheotomy  can  be 
performed.  A  constriction  sometimes  results  from  submucous 
infiltration  of  the  lining  membrane  of  the  trachea.  A  very 
remarkable  case  of  this  kind  is  recorded  in  the  volume  of  Dr. 
Gibb.' 

The  treatment  of  inflammation  of  the  trachea  would,  in  the 
main,  be  that  employed  for  acute  laryngitis,  onlj^  much  less 
active.  This  would  consist  in  rest,  warm  water  poultices  exter- 
nally, the  inhalation  of  steam,  impregnated,  if  desired,  with 
balsamic  or  anodyne  substances,  and  a  mild  antiphlogistic  course 

1  On  the  Throat  and  Windpipe,  2d  Edit.,  p.  397. 


392       AFFECTIONS    OF    THE    LAEYNX   AND    TEACHEA. 

internally.  An  acute  attack  might,  in  its  earliest  state,  be  aborted 
by  means  of  a  large  dose  of  opium,  or  the  local  ajjplication  of  a 
strong  solution  of  nitrate  of  silver.  Chronic  inflammation  of 
the  trachea  requires  treatment  similar  to  chronic  laryngitis. 
The  local  applications  may  be  made  with  the  sponge  probang, 
or  with  Gibb's  douche.  The  latter  instrument  can  always  be 
used  to  propel  solutions  down  the  trachea ;  the  passage  of  the 
sponge  requires  special  skill  in  manipulation.  Sulphate  of  zinc 
or  the  nitrate  of  silver  would  be  found  most  universally  appli- 
cable for  the  local  treatment  of  chronic  tracheitis.  I  have  seen 
a  great  deal  of  benefit  result  from  both  of  them.  The  treat- 
ment for  chronic  tracheitis  accompanying  tuberculosis  and  sy- 
philis would  be  that  detailed  for  the  chronic  laryngitis  attending 
these  diseases. 

A  somewhat  remarkable  case,  from  the  author's  practice,  is 
given  in  this  connection. 

Chronic  inflammation  of  the  Trachea,  of  Forty  Years' 

Standing,  cured  by  Nitrate  of  Silver. — Hannah  L ,  set. 

45,  called  upon  me  (April  1,  1867)  at  the  recommendation  of  Dr. 
Atkinson,  with  reference  to  treatment  for  a  chronic  sore  throat, 
which  she  had  had  as  long  as  she  could  remember.  It  must 
have  existed  then  for  at  least  forty  years.  There  was  evidence 
of  congestion,  on  laryngoscopic  inspection,  clear  down  the 
trachea.  There  were  several  warts  on  the  posterior  portion  of 
the  tongue,  to  the  left  side,  seemingly  of  textures  similar  to 
that  of  the  tongue,  and  perhaps  enlarged  or  aggregated  papillje. 
There  were  a  number  of  cutaneous  excrescences  on  the  face. 

A  sponge  saturated  in  a  solution  of  nitrate  of  silver,  sixty  grains 
to  the  ounce,  was  passed  down  the  entire  length  of  the  trachea, 
thoroughly  swabbing  the  parts,  every  other  day.  Within  a  week, 
the  relief  to  all  the  tracheal  symptoms  was  marked.  The  fre- 
quency of  the  application  was  diminished,  and  in  little  more 
than  two  months  she  was  discharged  from  treatment,  the  cure 
apparently  complete.  More  than  a  year  afterwards,  perhaps 
two,  Dr.  Atkinson  informed  me  that  the  relief  had  been  perma- 
nent. 


COlSrSTillCTIO]?^    OF    THE    TRACHEA.  393 

The  author  saw  a  case  of  ulceration  of  the  posterior  wall  of 
the  trachea,  in  the  body  of  a  young  man  who  died  suddenly, 
suffocated  by  an  accumulation  of  blood  in  the  trachea,  and  the 
post-mortem  examination  of  whose  body  he  was  invited  to  per- 
form by  Dr.  Shapleigh.  There  was  no  evidence  of  phthisis; 
and  the  larynx  was  normal.  There  had  been  hoarseness  during 
life  and  occasional  hemorrhage,  the  earliest  indications  having 
commenced  three  years  before  death,  and  subsequent  to  a  garot- 
ting  by  highwaymen.  The  ulceration  was  apparently  the  result 
of  simple  inflammation,  non-specific  and  non-tuberculous. 

COKSTEICTION    OF    THE    TEACHEA. 

Constriction  of  the  trachea  may  be  produced  by  the  presence 
of  aneurismal  or  other  tumors  outside  of  the  windpii3e.  This 
condition  is  to  be  carefully  discriminated  from  stricture  of  the 
tube,  the  result  of  disease  of  the  trachea  itself. 

The  constriction  may  be  due  to  compression  by  an  aneurism 
of  the  aorta,  cervical  abscesses,  enlarged  lymphatic  glands, 
tumors  of  the  neck,  benign  and  malignant,  goitrous  and  other 
tumors  of  the  thyroid  gland,  etc.  The  symptoms  of  this  con- 
dition of  things  would  be  those  of  impeded  respiration,  in 
marked  cases  amounting  to  dyspnoea,  and  in  severe  cases  pro- 
ceeding to  asphyxia.  The  existence  of  a  tumor  in  the  situations 
mentioned  would  lead  to  the  suspicion  of  compression  of  the 
trachea  if  dyspnosa  were  present.  Still  this  symptom  might 
exist  independently  of  any  compression  of  the  trachea,  being 
produced  by  compression  of  the  nervous  trunk.  Compression 
of  the  main  nerve,  or  of  the  inferior  laryngeal  fibres,  would  in 
like  manner  produce  aphonia,  which  may  therefore  coexist  as 
a  symptom  of  compression  upon  the  trachea  from  tlie  outside. 
The  encroachment  of  the  tumor  upon  the  calibre  of  the  tube 
has  often  been  observed  in  the  laryngoscopic  mirror.  Ttirck^ 
mentions  several  cases  of  this  kind,  and  depicts  the  images  seen 
in  the  laryngoscopic  mirror. 

.  The  treatment  for  this  condition  should  be  directed  to  the 
cause  producing  it,  as  the  sole  means  of  remedy.     Only  in  cases 

^  Op.  cit. ,  p.  507  et  aeq. 


394   AFFECTIONS  OF  THE  LAEYNX  AND  TEACHEA. 

where  the  tumor  was  high  up  in  the  neck  could  any  hope  of 
relief  be  held  out  from  the  operation  of  tracheotomy. 

Constriction  of  the  trachea,  the  result  of  a  cause  of  an  entirely 
different  nature  sometimes  exists,  and  may  be  mistaken  for  con- 
striction from  a  tumor  whose  presence  cannot  be  determined. 
For  a  knowledge  of  this  affection  we  are  indebted  to  Dr.  S. 
Scott  Allison,'  who  has  pointed  out  a  condition  of  the  trachea 
giving  rise  to  suspicion  of  tubercle  of  the  lung,  and  involving 
the  form  and  calibre  of  the  trachea,  and  which  has  received  little 
notice  from  pathologists.  This  condition  he  describes  as  one  of 
constriction  of  the  tube  immediately  above  its  bifurcation.  The 
extent  of  narrowing  varies,  but  is  very  manifest  to  the  eye  in 
many  cases.  It  affects  the  whole  circumference  of  the  tube, 
and  does  not  proceed  from  projections  at  particular  spots.  The 
cartilages  remain  of  normal  length,  the  soft  parts  of  the  pos- 
terior wall  only  being  reduced  in  breadth.  This  is  very 
obvious,  and  depends  usually  on  undue  muscular  contraction. 
No  morbid  lesions  are  found,  saving  narrowing  and  over-vas- 
cularity,  and  some  thickening  of  the  mucous  membrane ;  the 
calibre  of  the  narrowed  part  being  unduly  less  than  that  of  the 
trachea  in  its  upper  part. 

The  symptoms  which  this  condition  induces  are  described  as 
difficulty  in  both  inspiration  and  respiration,  with  auscultatory 
constrictive  phenomena  at  the  sternum,  great  sense  of  oppres- 
sion in  the  region  of  the  sternum  and  adjacent  parts  of  the 
chest,  liable  to  exacerbation  on  exposure  to  cold,  and  on  occa- 
sions of  increase  of  vascular  congestion,  or  of  spasmodic  action. 
It  may  give  rise  to  emphysema. 

A  similar  condition  of  the  trachea  is  described  as  occurring 
in  the  latter  stages  of  pulmonary  tuberculosis,  but  of  course 
there  would  not  be  any  doubt  then  as  to  the  diagnosis. 

The  aifection  under  consideration  is  looked  upon  by  Dr. 
Allison  as  comparatively  safe  and  generally  local,  despite  its 
occasional  accompaniments  of  general  derangement  of  health, 
loss  of  flesh,  cough,  and  occasional  streaky  hemoptysis.  Such  a 
case  would  be  treated  by  the  writer  by  the  passage  of  a  sponge 

loaded  with  a  solution  of  nitrate  of  silver. 

1  On  Morbid  Throat,  in  relation  to  Consumption.     London,  1869,  p.  12. 


CKOUP.  395 

FISTULE    OF    THE    LARYNX   AND    TEACHEA. 

A  fistnle  of  the  larynx  or  trachea  is  occasionally  met  with 
as  a  congenital  affection.  There  is  a  slight  discharge  of  mucus 
or  muco-piis  at  the  external  opening ;  and  it  is  differentiated 
from  fistule  of  the  pharynx  or  oesophagus,  or  a  iistule  connected 
with  one  of  the  bursse  in  this  region,  by  the  passage  of  an  ex- 
ploring probe  into  the  air-passage,  or  the  egress  of  air  from  the 
interior. 

A  subcutaneous  fistule  of  the  larynx  or  trachea  is  sometimes 
present,  of  which  I  have  seen  tM?"©  examples ;  one  in  a  young 
man,  a  journeyman  cigar-box  maker,  and  the  other  in  a  young 
lady  with  enlarged  cervical  glands  and  aphonia.  The  symptoms 
in  both  these  cases  were  very  similar.  A  sudden  emphysema- 
tous swelling  would  appear  in  front  of  the  neck  and  under  the 
jaw,  in  one  instance  pushing  the  tissues  forward  beyond  the 
chin,  and  of  course  producing  great  deformity.  Sometimes  the 
occurrence  would  take  place  within  a  few  minutes,  and  some- 
times the  tumor  would  not  attain  its  greatest  size  under  several 
hours.  It  would  gradually  subside  spontaneously  in  the  course 
of  a  day  or  two,  or  under  the  infiuence  of  friction  externally, 
but  sometimes  remain  for  three  or  four  days.  Though  making 
its  appearance  often  under  the  influence  of  emotion  or  exertion, 
it  would  occur  sometimes  without  any  apparent  cause. 

There  being  no  reason  to  believe  in  the  spontaneous  evolution 
of  gaseous  products  in  the  necks  of  these  individuals,  it  was 
presumed  that  a  fistule  existed  beneath  the  skin,  communicating 
with  the  larynx  or  trachea.  No  internal  evidence  of  fistulous 
opening  could  be  discovered  with  the  laryngoscope.  The  con- 
dition is  technically  known  as  pneumatocele. 

The  subject  of  traumatic  fistule  is  spoken  of  in  connection  with 
the  subjects  of  wounds  and  fractures  of  the  larynx  and  trachea. 

GROUP. 

Croup  is  a  peculiar  exudative  inflammation  of  the  mucous 
membrane  of  the  air-passages,  or  of  the  muciparous  glands 
upon  their  surface,  with  a  marked  disposition  to  the  induction 
of  paroxysmal  spasm  of  the  muscles  of  the  glottis,  and,  perhaps, 


396       AFFECTIONS    OF   THE    LARYNX   AND    TEACHEA. 

also  of  paralysis  of  the  nervous  fibrillse  distributed  to  the  minu- 
ter bronchi.  It  affects  the  mucous  membrane  of  the  larjaix  and 
trachea  chiefly,  but  sometimes  extends  into  the  bronchial  tract, 
and  not  unfrequently  implicates  the  pharyngeal  mucous  mem- 
brane also.  It  is  a  disease  which  attacks  the  adult  occasionally 
only,  the  greatest  predisposition  being  confined  to  a  period  ex 
tending  from  the  first  or  second  to  the  tenth  or  twelfth  year  of 
life  ;  although  it  is  sometimes  encountered  in  the  unweaned 
child.  From  some  cause  as  yet  undetermined,  male  children 
are  attacked  more  frequently  than  those  of  the  other  sex. 
Inasmuch  as  the  disease  is  most  prevalent  during  the  period  of 
the  first  dentition,  it  may  be  supposed  that  the  indiscreet  use  of 
food  unsuited  to  the  masticatory  and  digestive  organs  of  the 
child  has  some  influence  on  the  development  of  this  peculiar 
form  of  exudative  inflammation,  or  at  least  on  the  fostering  of  a 
predisposition  to  it. 

The  disease,  especially  in  its  fully  developed  form,  is  noto- 
riously fatal,  and  it  is  always  of  a  serious  character,  not  from 
the  amount  of  inflammatory  action  alone,  for  that  is  compara- 
tively insignificant  as  an  element  of  danger,  but  from  the  loca- 
tion of  the  exudative  product,  and,  in  a  less  degree,  from  the 
complication  of  spasm  of  the  glottis  ;  both  of  which  effects  may 
eventnate  in  suffocation. 

The  exciting  cause  of  croup  is  not  well  understood,  but  it 
seems,  in  the  majority  of  instances,  to  follow,  more  or  less,  ex- 
posure to  cold ;  sometimes  very  little  exposure  indeed. 

There  seems  to  be  three  distinct  varieties  of  this  disease,  one 
of  which  is  catarrhal,  with  an  exudation  of  mucus  merely ; 
another  is  fibrinous,  in  which  a  distinct  pseudo-membrane  be- 
comes deposited,  either  from  coagulation  of  the  exuded  albu- 
minous or  albumino-fibrinous  materials,  or  from  evaporation  of 
their  watery  constituents ;  and  a  third  variety,  which  is  but 
seldom  encountered,  in  which  there  is  an  actual  production  of 
pus. 

Laryngismus  stridulus,  spasmodic  or  false  croup,  is  a  nervous 
affection,  and  should  not  be  included  in  an  account  of  inflam- 
matory croup. 

There  is  spasm  of  the  glottis  in  almost  every  instance,  though 


CROUP.  397 

there  is  great  yariation  as  to  the  frequence  of  the  spasm,  and 
the  violence  of  the  paroxysm.  There  is  also  great  difference  in 
the  amount  of  dyspnoea,  which  nsually  presents  paroxysms  of 
temporarily  increased  difficulty  of  respiration.  This  dyspnoea  is 
sometimes  wholly  iuadeqnate  for  satisfactory  explanation  by 
reason  of  the  amount  of  exudation  ;  and  this  it  is  which  seems 
to  point  out  the  existence  of  an  element  of  paralysis  affecting 
the  nervous  distribution  at  the  ultimate  bronchi. 

Croup  is  usually  dependent  upon  causes  of  incidental  origin, 
but  there  appears  to  be  no  doubt  that  it  is  occasionally  epidemic. 
Certain  diseases  affecting  the  mucous  membranes  secondarily 
or  primarily,  such  as  influenza  often,  measles  frequently,  and, 
to  a  certain  extent,  scarlatina,  seem  to  induce  a  prevalence  to 
the  production  of  croup. 

The  catarrhal  form  of  croup  is  by  far  the  most  frequent ;  and 
both  the  membranous  and  purulent  varieties  are  apt  to  begin  in 
the  catarrhal  form. 

There  is  usually  a  little  febrile  movement  at  the  commence- 
ment of  an  attack  of  croup,  without  being  necessarily  preceded 
by  any  great  amount  of  chilliness,  though  it  is  often  difficult  to 
ascertain  the  truth  as  to  this  point.  The  indisposition  of  the 
child  generally  attracts  attention  for  the  first  time  towards  even- 
ing, the  child  speaking  with  a  voice  indicative  of  having  con- 
tracted a  cold,  and  coughing  a  little,  but  not  yet  with  the 
peculiarity  to  be  described  as  characteristic  of  the  affection. 
Still,  there  are  observers  who  assert  that  an  acute  ear  is  able  to 
detect  the  peculiar  quality  of  the  cough  from  its  very  com- 
mencement. Sometimes,  for  two  or  three  days,  the  symptoms 
are  only  those  of  slight  catarrh.  After  a  day  or  two — it  may 
be  four  or  five — towards  night,  there  gradually  appears  a  slight 
fl-ush  upon  the  countenance  of  the  child,  with  an  abnormal 
brilliancy  of  the  eye,  some  increased  heat  of  skin,  and  a  quick- 
ness and  fulness  of  the  pulse.  At  a  period  varying  between 
an  hour  or  two  before  midnight,  or  thereabouts,  the  child  is 
likely  to  be  awakened  by  the  onset  of  an  attack  of  dyspnoea, 
which  is  often  the  first  symptom  exciting  the  alarm  of  its 
parents ;  but  sometimes  this  does  not  occur  until  early  in  the 
morning ;  and  it  is  at  this  period  usually  that  the  peculiar  char- 


398       AFFECTIONS    OF   THE   LAEYISTX    AND    TEACHEA. 

acter  of  the  congli  is  detected.  This  congh  is  very  characteristic, 
and  is  recognized  when  first  heard  by  a  medical  practitioner, 
and  remembered  ever  after.  A  description  conveys  no  adequate 
idea  of  its  peculiarity.  It  has  a  specific  ring  to  it,  which  has 
been  compared  to  the  crowing  of  a  cock,  and  to  the  resonance 
of  a  brass  tube. 

The  cough  is  at  first  sonorous,  but  undergoes  gradual  changes 
into  huskiness,  and  finally  in  some  instances  becomes  almost 
toneless,  the  child  being  seen  to  cough  but  not  heard  in  so  doing. 
The  voice,  which  is  at  the  first  nearly  natural,  becomes  hoarse 
and  dissonant,  acquiring  a  peculiar  quality  suggestive  of  the 
characteristics  of  the  sound  of  the  cough ;  and,  as  the  disease 
progresses,  it  changes  into  a  dull  husky  laryngeal  whisper,  which 
gradually  becomes  extinct.  The  dyspncea  increases  likewise, 
until  finally  there  are  presented  all  the  phenomena  of  struggling 
for  breath,  with  distention  of  the  nostrils,  protrusion  of  the  eye- 
balls, clutching  at  the  throat,  and  grasping  at  the  arms  of  the 
attendants,  as  though  to  find  a  fulcrum  to  aid  the  action  of  the 
muscles  of  respiration  ;  the  flush  disappears  from  the  face  of  the 
child,  which  becomes  pale,  more  or  less  purplish,  while,  at  the 
same  time,  there  is  lividity  of  the  lips,  and  an  anxious  expres- 
sion of  countenance,  indicative  of  the  greatest  distress. 

These  severe  symptoms  are  not  always  manifested  on  the  very 
first  day  of  the  disease,  but  come  on  gradually  in  the  course  of 
two  or  three  days,  and  with  increasing  significance.  In  the  early 
stage  of  the  affection  the  only  source  of  iunnediate  danger  to 
life  exists  in  the  paroxysmal  spasm  of  the  glottis  ;  but  at  a 
later  date,  when  the  exudative  process  has  become  fully  de- 
veloped, there  is  superadded  a  danger  of  suffocation  in  conse- 
.  quence  of  the  obstruction  of  the  air-tube. 

Croup  may  run  its  course  to  a  fatal  termination  in  forty- 
eight  or  even  twenty-four  hours,  but  this  is  unusual ;  its  general 
duration  being  from  five  to  eight  days,  though  cases  are  oc- 
casionally encountered  in  which  the  attack  continues  for  two  or 
three  weeks,  or  even  longer  according  to  some  observers,  and 
in  some  instances  a  continuous  liability  to  its  attacks  seems  to 
be  kept  up  for  a  period  of  several  months. 

In  the  absence  of  direct  or  laryngoscopic  inspection  of  the  de- 


CROUP.  399 

posit,  tlie  only  certain  diagnosis  in  a  case  of  membranous  cronp 
is  tlie  expulsion  of  some  of  the  products  of  exudation.  These 
may  appear  in  ir]-eo:ular  flakes,  or  as  thickened  mucus ;  in  some 
instances  large  flakes  are  coughed  out  bearing  the  impress  of 
the  tracheal  cartilages,  sometimes  in  shreds,  sometimes  in  rings, 
sometimes  in  tubes,  sometimes  in  solid  balls.  Instances  are  on 
record  in  which  regular  casts  of  the  trachea  and  portions  of  the 
bronchi  have  been  expectorated,  and  similar  casts  of  great  ex- 
tent have  been  found,  not  infrequently,  on  post-mortem  exami- 
nation. The  appearance  of  fibrinous  deposits  upon  the  tonsils, 
palatine  arches,  or  pharynx,  is  also  indicative  of  the  nature  of 
the  disease,  but  is  by  no  means  to  be  relied  on  as  an  essential 
feature.  Laryngoscopic  inspection,  in  the  hands  of  very  skilful 
manipulators,  has  detected  the  presence  of  the  membrane  within 
the  larynx  and  the  trachea,  even  in  very  young  childi-en.  In  chil- 
dren of  four  or  five  years  of  age  and  upwards,  such  an  exami- 
nation offers  no  great  difiiculty  to  execution.  When  there  are 
no  evidences  of  this  kind  upon  which  to  base  a  judgment,  the 
case  is  supposed  to  be  croup  from  the  general  symptoms, 
coupled  with  the  history  of  the  case  ;  and  if  there  is  any  doubt 
upon  the  subject  the  case  is  to  be  treated  as  though  there  were 
no  doubt  at  all  of  its  being  croup,  in  order  to  secure  the  advan- 
tage of  judicious  treatment  in  the  early  stage,  a  point  of  great 
moment  in  the  management  of  this  dangerous  and  often  insidi- 
ous disease.  Croup  is  one  of  those  diseases  in  which  early  at- 
tention will  have  a  very  great  infiuence  upon  the  result,  an 
influence  often  of  life  over  death ;  and  it  is  therefore  incum- 
bent upon  the  physician  to  avoid  any  unnecessary  delay  in  ren- 
dering service.  Were  this  the  rule  more  than  it  is,  better  re- 
sults, perhaps,  than  are  usually  observed  would  follow  the  treat- 
ment of  croup. 

The  treatment  of  croup  is  a  subject  about  which  there  is  very 
little  uniformity  in  the  practice  of  physicians.  To  designate, 
merely,  the  various  methods  that  have  been  recommended, 
would  require  many  pages.  All  that  the  author  can  do,  in  the 
space  allotted  to  this  topic,  is  to  describe  the  plan  of  treatment 
which  seems  to  him  most  rational,  and  which,  with  such  modi- 
fications as  each  individual  case  has  required,  has  best  served 
the  purpose,  in  the  actual  test  of  his  practice.     The  main  prin- 


400   AFFECTIONS  OF  THE  LARYNX  AND  TRACHEA. 

ciple  in  view  is  to  sustain  strength  while  assisting  the  patient 
throngh  the  natural  course  of  the  disease. 

The  most  frequent  variety  of  croup  is  the  raucous  or  catarrhal 
form,  in  which  there  is  little  disposition,  if  any,  to  the  con- 
gellation  of  the  exudation  into  a  membrane.  The  treatment 
of  this  form  would  be  but  little  different  from  that  of  a  case  of 
ordinary  catarrh,  save  that  the  patient  would  be  kept  in  bed,  in 
a  well-ventilated  room  warmed  to  a  temperature  of  not  less 
than  80°  F.,  and  that  the  air  of  the  apartment  would  be  kept  very 
moist  by  means  of  an  atmosphere  of  steam  produced  in  one  of 
the  methods  to  be  described  presently.  If  the  child  were  too 
young  to  make  voluntary  efforts  at  expectoration,  an  emetic  of 
alum,  as  employed  by  the  late  Prof.  Meigs,  would  be  given 
about  twice  in  the  twenty-four  hours,  in  order  to  provoke  ex- 
pectoration during  the  act  of  vomiting,  and  this  only  for  the 
reason  that  the  air-passages  of  children  are  too  tolerant  of 
mucous  accumulations,  to  run  any  risk  of  their  increasing  to 
such  extent  as  to  offer  any  unpleasant  mechanical  complication 
during  the  management  of  the  case.  The  bowels  would  be 
kept  open,  if  need  for  this  appear,  by  the  oleaginous  mixture  or 
by  bicarbonate  of  soda,  or  some  other  gentle  laxative.  The 
diet  would  consist  of  milk  if  the  child  be  young ;  or  of  beef 
tea  and  other  meat  broths,  or  soups  with  a  moderate  allowance 
of  farinaceous  food,  if  the  child  be  a  few  years  of  age.  If 
symptoms  of  debility  present  themselves,  quinine  and  iron,  pre- 
ferably in  the  form  of  the  muriate,  would  be  administered. 
And  finally,  if  there  were  a  good  deal  of  inflammatory  action  in 
the  parts,  the  throat  would  be  enveloped  in  a  wet  cotton  poul- 
tice, covered  with  oiled  silk. 

"Where  there  was  reason  to  suppose  that  the  exudation  was 
being  deposited  in  the  form  of  a  membrane,  the  treatment 
would  be  more  active.  The  temperature  of  the  apartment 
would  be  kept  at  from  85°  to  90°  F.,  and  the  atmosphere  would 
be  more  loaded  with  steam  ;  with  the  object  in  view  of  supply- 
ing, to  the  exudation,  water  to  replace  that  which  is  lost  by 
evaporation  or  coagulation  of  the  exudation  in  the  formation  of 
the  membrane.  With  this  view,  I  have  often  maintained  so  great 
an  evolution  of  steam  that  the  paper  of  the  room  has  hung 


CROUP.  401 

loose  from  the  walls.  Wliere  a  stove  can  be  placed  in  the 
room,  a  large  vessel  of  water  containing  a  few  towels  is  placed 
npon  it.  The  presence  of  the  towels  or  napkins,  or  whatever 
may  be  employed,  assists  the  evolution  of  the  steam.  If  this  be 
insufficient,  wet  cloths  are  hung  upon  chairs  and  arranged  near 
the  fire,  the  cloths  being  wet  again  as  soon  as  they  become  dry ; 
a  clothes-line  is  hung  in  the  roc<m  and  wet  sheets  and  other 
articles  placed  upon  it.  Under  other  circumstances  I  have  had 
the  family  wash-kettle  brought  into  the  room  filled  with  boiling 
Avater,  and  kept  a  servant  by  it,  constantly  lifting  out  articles  of 
clothing  and  again  immersing  them.  At  the  same  time  a 
second  wash-kettle  is  on  the  kitchen  fire,  ready  to  replace  the 
one  in  use  as  soon  as  its  water  fails  to  give  off  sufficient  steam. 
Buckets  of  M'ater  into  which  hot  bricks  and  bits  of  heated  iron 
are  thrown,  also  afford  a  method  of  keeping  up  a  su2:)ply  of 
steam.  In  summer-time,  and  at  other  times  where  a  stove  can- 
not be  procured,  a  gas  stove  may  be  fed  by  the  illuminating 
gas  and  furnish  a  means  of  warmth ;  while  the  croup-kettle  now 
furnished  by  the  surgical  instrument  makers  can  be  placed 
upon  it  for  the  purpose  of  affording  the  steam ;  and  this  plan 
has  the  advantage  that  by  means  of  long  tubing  the  entire  ap- 
paratus can  be  brought  close  to  the  bedside  of  the  patient.  The 
air  of  the  apartment  is  kept  ventilated  by  opening  a  window  in 
an  adjoining  room  or  staircase,  a  screen  form-ed  by  a  sheet  or 
quilt  upon  a  line  being  placed  in  front  of  the  door  of  commu- 
nication so  as  to  screen  the  patient  from  draught.  This  tempera- 
ture and  steaming  is  kept  up  night  and  day,  as  long  as  there 
seems  any  occasion  for  it,  the  amount  of  heat  and  steam  being 
then  lessened  gradually.  In  order  to  assist  in  the  destruction  of 
the  membranes  as  soon  as  formed,  and  to  afford  inlets  through 
them  for  the  watery  vapor  to  get  beneath  them  so  as  to  facil- 
itate their  removal  without  waiting  for  the  period  of  suppura- 
tion, resort  is  made  every  half -hour,  hour,  or  two  hours,  as  the 
case  may  seem  to  require,  to  the  inhalation  of  the  vapor  fi'om 
slackening  lime,  as  recommended  by  Dr.  Geiger — a  method 
much  better  than  that  of  nebulizing  the  lime-water  into  spray. 
"Where  the  vapor  charged  with  lime  does  not  seem  to  be  doing 

good  service,  I  have  sometimes  met  with  good  results  from  the 
26 


402       AFFECTIONS    OF    THE    LARYNX    AND    TRACHEA. 

use  of  bromine  inhalations  as  recommended  by  Ozanam,  the 
fqrmnla  being  a  grain  of  bromine,  a  drachm  of  bromide  of 
potassium,  and  an  ounce  of  water,  which  quantity  is  nebulized 
into  spray  by  the  steam  apparatus,  and  diluted  only  so  far  as  the 
case  may  seem  to  require.  Alternation  back  to  the  lime  after  the 
use  of  the  bromine,  seems  sometimes  to  be  indicated  and  to  offer 
good  results.  These  inhalations  are  continued  from  ten  to  twenty 
minutes  at  a  time  at  suitable  intervals  night  and  day, irrespecti\e 
of  sleep,  and  veiw  often  succeed  in  forcing  the  detacdiment  and 
expulsion  of  shreds  of  membrane,  sometimes  in  copious  masses. 
They  are  intermitted  from  time  to  time,  if  the  respiration  has 
remained  much  improved  for  a  number  of  hours  continuously, 
and  are  resorted  to  again  upon  the  least  sign  of  any  fresh  em- 
barrassment in  breathing.  Care  must  be  taken  in  some  instance 
to  remove  the  secretions  from  the  mouth,  as  they  sometimes  ac- 
cumulate there  and  may  prove  dangerous. 

There  is  great  risk,  in  this  treatment,  of  exciting  catarrhal 
bronchitis  or  pneumonia,  conditions  which  often  occur  without 
the  treatment,  but  the  risk  of  this  is  not  greater  than  the  risk  of 
death  under  inefticient  treatment ;  and  if  the  child  is  saved 
from  death  by  the  croup,  we  have  a  fair  opportunity  to  carry 
him  through  his  pneumonia  by  being  on  the  alert  to  detect  its 
earliest  manifestations.  At  least,  I  have  never  seen  death  from 
this  cause  after  a  successful  management  of  the  croup  by  the 
method  narrated,  although  1  have  sometimes  been  mentally 
prepared  for  it.  The  emetic,  in  young  infants,  in  this  form  of 
the  disease,  is  given  at  intervals  of  not  longer  than  six  hours,  as 
long  as  there  remain  any  evidences  of  continued  formation  of 
membrane  ;  and  if  the  alum  prove  insufficient  for  the  purpose, 
as  it  sometimes  will,  I  resort  to  a  strong  decoction  of  senega,  or 
to  ipecacuanha,  never  to  tartar-emetic,  and  rarely  to  sulphate  of 
copper  or  the  turpeth  mineral.  The  picture  that  Prof.  Nie- 
meyer  has  drawn  of  an  infant  bathed  in  the  bluish  excretions 
from  its  rectum,  when  the  emetic  has  ceased  to  operate  upon  the 
stomach,  is  too  horrible  for  one  to  wish  to  persist  in  the  use  of 
sulphate  of  copper  once  it  has  proved  inactive. 

Opium,  in  the  form  of  paregoric  or  otherwise,  or  l)elladonna, 
or  some  other  narcotic  remedy,  is  sometimes  required  as  a  means 


CEOUP.  403 

of  repressing  the  tendency  of  spasm.  The  warm-water  dressing 
is  kept  applied  to  the  outside  of  the  throat,  and  sometimes  re- 
placed by  a  flaxseed  poultice. 

In  addition  to  the  nourishing  diet  and  tonic  treatment  re- 
sorted to  in  the  milder  cases,  systematic  stimulation  with  alcohol 
and  with  carbonate  of  ammonia  is  employed.  Time  and  again 
I  have  seen  a  full  dose  of  carbonate  of  ammonia  rouse  a  child 
from  complete  exhaustion,  and  tide  its  fleeting  life  over  the  ten 
or  fifteen  minutes  necessary  to  administer  the  inhalation  of  the 
vapor  of  lime,  or  the  spray  of  bromine,  affording  another 
chance  for  the  detachment  of  newly-formed  membrane.  When 
cerebral  symptoms  supervene,  I  resort  to  calomel  in  small  and 
frequent  doses.  I  have  never  had  occasion  to  resort  to  trache- 
otomy to  save  the  life  of  a  child  with  croup.  Should,  however, 
a  case  occur,  in  which  the  method  of  treatment  narrated,  fairly 
carried  out,  failed  to  afford  relief,  and  in  which  it  was  not 
evident  that  the  exudation  occupied  the  bronchial  tubes,  I  would 
resort  to  tracheotomy  as  soon  as  there  was  any  evidence  of  con- 
tinued dyspnoea  threatening  suffocation,  without  waiting  for 
the  actual  symptoms  of  impending  asphyxia,  in  the  con\iction 
that  an  early  performance  of  the  operation  offers  tlie  best  chance 
of  saving  life  by  it.  But  it  is  due  to  the  treatment  above  nar- 
rated to  say,  that  I  have  seen  the  life  of  a  patient  preserved 
through  it,  if  not  by  means  of  it,  for  whom  the  jDcrformance  of 
the  operation  of  tracheotomy  had  been  declined  by  more  than 
one  surgeon,  as  offering  no  chance  of  a  successful  result. 

The  local  application  of  solutions  of  nitrate  of  silver,  a  drachm 
and  more  to  the  ounce,  has  been  highly  extolled  by  Prof.  Green,. 
Dr.  Gibb,  and  many  others,  and  is  very  beneficial  in  many  in- 
stances, in  some  of  them,  doubtless,  by  the  mere  mechanical  de- 
tachment of  the  membrane  removed  by  the  contact  of  the 
sponge  in  the  performance  of  the  operation.  It  is  only  upon 
this  view  that  we  can  explain  the  benefit  attributed  to  very  in- 
different substances  employed  in  the  same  maimer.  The  salts 
of  iron  are  sometimes  employed  in  the  same  way  as  the  nitrate 
of  silver.  I  have  never  felt  any  inclination  to  employ  local  re- 
medies in  this  wa}^,  though  as  bold  as  most  practitioners  with 
regard  to  manipulation  within  the  larynx.     The  inhalation  of 


404        AFFECTIONS    OF    THE    LAEYISTX   AI^D    TRACHEA. 

sulphuric  ether,  so  highly  extolled  in  the  journals  a  few  years 
ago,  I  tried,  at  the  time,  in  two  or  three  cases  in  the 'manner 
described  by  those  who  recommended  it,  but  without  witnessing 
any  result  which  seemed  to  justify  any  further  resort  to  it.  In 
one  instance,  in  particular,  that  I  well  remember,  and  to  which 
I  was  called  too  late  to  allow  any  time  for  the  action  of  the  va- 
por of  lime,  wliich  had  been  used  slightly  but  not  with  the  re- 
quisite pertinacity,  and  in  which  it  was  evident  that  tracheotomy 
was  inapplicable,  the  ether  was  tried,  but  without  producing 
any  of  the  favorable  results  recorded  as  having  occurred  under 
similar  circumstances, 

A  child  who  has  passed  through  an  attack  of  membranous 
croup,  especially  if  it  has  been  actively  treated  on  the  steaming 
and  inhalatory  principle,  should  be  confined  to  the  house  for  a 
long  time,  and  the  greatest  circumspection  should  be  exercised 
with  regard  to  its  diet  and  clothing.  The  reduction  of  the  tem- 
perature of  the  bed-room  to  that  of  the  rest  of  the  house  should 
be  accomplished  gradually,  and  not  occupy  less  than  forty-eight 
hours.  The  voice  of  the  patient  who  has  had  membranous  croup 
does  not  always  return  at  once ;  sometimes  weeks  and  even 
months  elapse  before  the  voice  becomes  natural  again.  This  is 
due  sometimes  to  infiltration  or  thickening  of  the  vocal  cords, 
and  sometimes  to  the  formation  of  little  vegetations  upon  them, 
or  in  their  neighborhood.  Both  of  these  conditions  seem  to  sub- 
side gradually  without  the  intervention  of  any  special  treatment. 
Should  such  treatment  seem  indicated,  iodide  of  potassium  or 
muriate  of  anmionia,  perhaps,  would  present  itself  as  the  most 
suitable  remedy ;  assisted,  probably,  by  the  daily  inhalation  of 
a  spray  of  a  weak  solution  of  tannin  or  other  astringent. 

With  regard  to  inhalations  of  lactic  acid,  as  recommended  by 
Dr.  Weber,  and  inhalations  of  sulphurous  acid,  sulphuret  of 
mercury,  and  other  substances  said  to  be  able  to  disintegrate  the 
membrane,  I  can  only  say  that,  in  my  own  hands,  they  have  not 
produced  results  as  apparently  beneficial  as  the  lime  and  the 
bromine ;  and  though  I  have  resorted  to  them  occasionally,  I 
have  always  felt  disposed  to  fall  back  upon  the  lime  and  the 
bromine. 

The  use  of  the  inhalation  of  oxygen  gas  has  been  recommend- 


CROUP.  405 

ed  in  the  treatment  of  croup  as  a  means  of  counteracting  the 
baneful  effects  of  the  carbonic  acid  producing  the  asphyxia,  and 
in  the  hands  of  Beigel,  Michel,  and  others,  has  proved  occasion- 
ally successful.  It  has  even  been  proposed  as  a  snbstitute  for 
tracheotomy,  but  this  it  cannot  be,  as  long  as  the  aperture  of  the 
glottis  is  diminished  by  swelling  or  false  membrane.  Atmo- 
spheric air  is  wanted,  not  oxygen,  and  if  the  glottis  be  too  small 
to  admit  of  a  proper  supply,  a  larger  opening  should  be  made 
artificially  for  this  purpose.  If  an  operation  of  this  kind  is  not 
indicated,  it  would  appear  more  rational  to  employ  a  substance 
capable,  under  favorable  conditions,  of  disintegrating  the  mem- 
brane. 

The  vapor  of  liquor  annnonia,  from  a  sponge  held  in  the 
pharynx  a  few  moments  at  a  time,  has  been  recommended  by 
Dr.  Daguillon,  of  Oran,'  the  parts  being  washed  afterwards  with 
fresh  water. 

The  internal  administration  of  cubebs,  which  certainly  has  a 
disposition  to  elimination  by  the  bronchial  mucous  membrane, 
has  been  recommended  by  Trideau,  C.  Paul,  and  others,  but  I 
am  unable  to  pass  judgment  upon  it.  It  would  be  more  ser- 
viceable in  the  catarrhal  form  of  croup,  reasoning  from  analogy, 
than  in  the  membranous  variety. 

In  order  to  insure  the  access  of  air  to  the  lower  air-passage 
without  the  performance  of  tracheotomy,  tubage  of  the  larynx 
has  been  recommended ;  but  the  results  have  not  been  very 
promising,  tracheotomy  having  become  absolutely  necessary  in 
a  number  of  cases  thus  treated.  The  treatment  is  better  in. 
theory  than  in  practice. 

When  tracheotomy  is  performed  in  the  course  of  a  case  of 
croup,  it  should  not  be  forgotten  that  it  accomplishes  but  a  single 
object,  it  permits  a  greater  access  of  atmospheric  air.  The  medi- 
cinal treatment  is  by  no  means  to  be  interrupted.  Indeed,  the  use 
of  tonics  and  stimulants  are  sometimes  more  strongly  indicated 
thereby  from  the  fact  that  the  child  often  experiences  such  diili- 
culty  in  swallowing,  that  a  proper  amount  of  iiourishment  can- 
not be  obtained  by  the  mouth ;  and,  in  addition,  he  has  to  over- 

1  Gaz.  hebd.,  Nov.  30,  1870.     Eanking's,  Abst.  Jan.  1,  1871,  p.  65. 


406        AFjbECTIONS    OF    THE    LAEYNX    AISTD    TEACIIEA. 

come  the  nervous  sliock  incident  to  the  operation.  Great  care 
is  I'equired  as  to  cleanliness  of  the  iinier  tube,  for  a  double  tube 
should  always  be  employed.  In  some  instances  the  irritation, 
produced  by  the  tube  is  so  great  as  to  necessitate  its  withdrawal, 
and  the  section  of  the  sides  of  the  wound,  so  as  to  secure  au 
oval  opening,  at  least  the  size  of  the  normal  glottis,  for  the 
access  of  air.  The  opening  in  the  trachea  affords  an  avenue  for 
the  direct  iutroduction  of  local  remedies,  calculated  to  act  upon 
the  membrane,  and  this  use  of  it  may,  no  doubt,  prove  valuable 
in  certain  cases.  Lime  water,  solutions  of  chlorate  of  potassa, 
chlorate  of  soda,  etc.,  have  been  injected  in  this  way  with 
success.  In  this  connection  it  may  be  well  to  mention  that 
these  substances  have  been  injected  directly  into  the  larynx  and 
trachea  by  means  of  a  curved  sharp-pointed  syringe,  rather 
larger  than  the  hypodermic  springe,  plunged  from  the  outside 
through  the  crico-thyroid  ligament.  It  is  a  plan  which  Avould 
not  appear,  at  first  sight,  to  possess  any  advantage  over  the 
method  of  inhalation,  and  it  may  pcjssibly  prove  directly  injurious 
by  wounding  an  artery  of  anomalous  distribution. 

Dr.  Sanne  ^  has  recently  written  an  excellent  volume  of 
nearly  300  pages,  on  the  Study  of  Croup  after  Tracheotomy, 
based  upon  eighty-three  cases  operated  upon  in  the  Saint 
Eugenie  Hospital  in  1868. 

GEOWXnS    IX    THE    LARTXX. 

Growths  in  the  larynx  are  not  of  infrequent  occurrence,  though 
they  were  supposed  to  be  very  rare  before  the  introduction  of 
the  laryngoscope  as  a  means  of  diagiK.^sis.  Indeed,  seventy  cases, 
probably,  would  represent  the  entire  number  on  record  before 
the  invention  of  that  instrument,  while  since  its  use  has  become 
general,  several  hundreds  have  been  recorded.  The  fact  is,  that 
the  subjective  symptoms  to  which  growths  in  the  larynx  give 
rise  were  not  such  as  to  point  prominently  to  the  presence  of  a 
neoplasm,  except  in  \'ery  marked  cases  ;  while,  at  present,  it  is 
so  customary  to  make  a  laryngoscoj)ic  examination  in  diseases 
of  the  throat,  that  many  tumors,  or  at  least  excrescences,  are 

'  Etude  sui'  le  croup  aprcs  la  trachcotomie.     Paris,  1S69. 


GROWTHS    IN    THE    LARYISTX.  407 

discovGred  whose  existence  would  not  have  been  suspected  other- 
wise. The  use  of  the  laryngoscope,  too,  has  tanght  us  to  inter- 
pret the  subjective  symiDtoms  of  this  form  of  disease  better 
than  we  used  to  do ;  and  it  is  not  now  uncommon  for  one  ac- 
customed to  meet  such  cases,  to  suspect  their  existence  at  once, 
by  the  voice  and  manner  of  the  patient,  before  making  any 
resort  to  the  laryngoscopic  mirror. 

The  general  symptoms  of  a  foreign  growth  in  the  larynx  vary 
with  the  size  of  the  neoplasm  and  with  its  seat.  Some  growths 
give  rise  to  no  special  symptoms  at  all,  and,  as  already  inti- 
mated, are  accidentally,  or  rather  nnsuspectingly  discovered 
upon  laryngoscopic  examination,  undertaken  with  a  view  to 
deternnne  the  cause  of  an  obstinate  affection  apparently  trifling 
in  character. 

The  usual  symptoms  of  a  laryngeal  growth,  when  large 
enough  to  interfere  with  function,  or  when  situated  u23on  an 
important  part  of  the  structures,  are :  cough  ;  alteration  of  voice  ; 
dyspnoea  ;  dysphagia  ;  and  pain. 

Cougli  is  not  a  fi'equent  symptom  unless  the  growth  bo  near 
the  gh.ttis,  very  large,  or  vascular  and  apt  to  bleed.  The 
character  of  the  cough  may  be  dry  and  hacking,  or  moist  and 
accompanied  by  expectoration  varying  in  character  and  con- 
sistence. AVhen  vibration  of  the  lips  of  the  glottis  is  interfered 
with,  the  tone  of  the  cough  will  be  rough,  hoarse,  whispering, 
or  aphonic.  When  the  growth  is  large,  the  sound  of  the  cough 
is  often  quite  similar  to  that  of  the  cough  of  croup. 

Alteration  of  voice  occurs  only  v\^hen  the  growth,  by  its  seat 
or  its  size,  interferes  with  the  due  vibration  of  the  vocal  cords. 
A  growth  upon  the  vocal  cords,  between  them  or  beneath  them, 
will  produce  a  hoarseness  of  the  voice  even  when  the  growth  is 
very  small  ;  but  a  grcjwth  upon  other  portions  of  the  larynx  will 
not  interfere  seriously  with  the  voice  unless  it  extends  per- 
manently or  at  times  within  the  chink  of  the  glottis,  or  presses 
upon  one  or  both  vocal  cords  so  as  to  impede  their  free  vibra- 
tion. Where  a  growth  is  so  situated  as  only  at  times  to  inter- 
fere with  the  functions  of  the  vocal  cords,  the  hoarseness  or 
dysphonia  will  be  intermittent,  and  this  intermittence  may  show 
itself  more  than  once  during  the  utterance  of  a  sino-le  sentence. 


408        AFFECTIOlSrS    OF   THE    LARYNX   AND    TRACHEA. 

A  small  growth  upon  the  vocal  cords  may  entangle  a  clump  of 
mucus  now  and  then,  and  thns  give  rise  to  a  sudden  hoarseness 
or  aphonia,  which  ceases  as  suddenly,  upon  detachment  of  the 
mucus.  According  to  the  position  of  a  small  growth  upon  the 
vocal  cords,  especially  in  cases  of  symmetrical  excrescences  u23on 
both  cords,  the  alteration  of  the  voice  will  be  found  to  concern 
a  certain  portion  of  the  musical  scale,  its  pitch  varying  with  the 
length  of  cord  in  vibration,  in  obedience  to  the  laws  of  acoustics. 
In  this  way  a  double  vocal  sound  is  produced  by  a  growth 
situated  upon  the  anterior  third  of  the  cords,  and  thus  dividing 
them  into  four  vibrating  reeds.  Unless  the  growth  is  quite 
large,  or  protrudes  within  the  chink  of  the  glottis,  actually  pre- 
venting its  closure,  there  will  not  be  apt  to  be  complete  aphonia. 
Sometimes  the  voice  is  uneven,  that  is  to  say,  hoarse,  aphonic, 
and  shrill,  at  irregular  intervals  during  speech.  Usually  there 
is  a  characteristic  dull  timbre  to  the  aphonic  or  dysphonic  into- 
nation, sufyo-estive  of  mechanical  obstruction,  and  differentiating 
it  at  once  from  hoarseness  and  dysphonia  the  result  of  other 
causes. 

Dyspnoea  is  not  present  unless  the  growth  is  comparatively 
large,  so  as  to  offer  obstruction  to  the  serial  current,  or  unless  the 
parts  become  swollen  in  consequence  of  intercurrent  catarrhal 
inflammation.  The  dyspnoea  will  be  irregularly  intermittent 
unless  the  growth  be  very  large.  The  dyspnoea  will  vary,  with 
the  case,  from  mere  embarrassment  of  breathing,  to  distress  of 
the  severest  character,  threatening  asphyxia.  In  many  in- 
stances the  dyspnoea  can  be  relieved  by  change  of  po&ition  of 
the  head,  a  symptom  which  is  indicative  of  a  movable  tumor. 
Cases  are  on  record  in  which  growths  of  this  kind  have  pro- 
duced asphyxia.  Two  such  cases,  in  which  the  patients  were  fore- 
warned of  the  result  by  the  author,  occurred  in  individuals,  with 
tumors  within  the  glottis,  who  declined  surgical  interference. 

The  tumors  were  not  very  large  in  either  instance,  as  will  be 
seen  by  reference  to  the  accompanying  illustrations,  Figs.  71 
and  72  ;  but  they  were  in  dangerous  locations,  and  seriously  com- 
pr'  imised  the  integrity  of  the  glottis. 

As  these  cases  are  particularly  instructive,  they  are  placed  on 
record. 


GEOWTHS  m   THE  LARYNX. 


409 


A.  S ,  aged  40,  a  brewer,  was  brought  to  me  N"ovember  9th, 

1868,  b}^  Dr.  Bloom,  of  Philadelphia,  to  be  examined  as  to  the 
cause  of  a  chronic  hoarseness  which  had  existed  for  upwards  of 
twenty-five  years.  The  patient  had  chronic  follicular  pharyn- 
gitis, with  congestion  of  the  larynx.  The  vocal  cords  were 
thickened  and  very  red  in  color,  and  upon  each  of  them  was  an 


Fig.  Tl. 


Turaors  on  both  vocal  cords, 
producing  sudden  death. 


Tumor  on  left  vocal  cord, 
producing  sudden  death. 


irregular  flabby  growth  also  very  red  in  color.  As  the  patient 
was  suffering  from  a  little  sore  throat  at  the  time,  it  was  im- 
possible to  determine  whether  the  color  of  the  growths  was 
simply  due  to  temporary  injection  of  their  mucous  covering,  or 
whether  this  was  their  ordinary  aspect.  The  appearance  is  de- 
picted in  Fig.  Tl.  An  operation  for  removal  of  these  growths 
was  urged  upon  the  patient,  to  which  he  consented  ;  and  making 
an  appointment  for  a  subsequent  interview,  he  left  my  house.  I 
never  saw  him  again.  Some  months  afterwards,  Dr.  Bloom  in- 
formed me  that  the  patient  had  been  dissuaded  by  his  wife  from 
undergoing  the  operation,  and  that  he  had  died  suddenly.  The 
patient  attributed  his  disease  to  syphilis  contracted  when  very 
young. 

Wm.  McN •,  set.  56,  a  shoemaker,  was  sent  to  me  March 

1st,  1869,  by  Dr.  Shapleigh,  of  Philadephia,  who  examined  him 
with  me  at  a  second  interview  on  the  following  day.  A  red 
irregular  tumor  was  found  upon  the  left  vocal  cord.  Its  ap- 
pearance is  shown  in  Fig.  72.  Dysphonia,  with  paroxysms  of 
distressing  dyspnoea,  had  existed  for  about  a  year.  The  patient 
had  contracted  syphilis  years  before,  but  was  otherwise  in  gene- 
ral good  health.  An  operation  was  urged  upon  this  patient  also, 
and  an  appointment  was  made  for  tentative  procedure,  which 


410        AFEECTIOIS'S    OF    THE    LARYNX    AND    TRACHEA. 

a23pointment  was  never  kept.  A  few  weeks  later  I  was  in- 
formed by  Dr.  Shapleigh  that  he  had  been  told  by  the  friends 
of  this  patient  that  he  had  sought  relief  elsewhere,  and  was 
placed  under  treatment  for  syphihtic  laryngitis,  part  of  which 
consisted  in  cauterizing  the  larynx  with  the  ordinary  sponge- 
probang ;  and  that  having  died  suddenly,  a  post-mortem  exami- 
nation had  been  made,  revealing  the  presence  of  the  tumor,  to 
the  existence  of  which  the  death  had  been  attributed. 

These  were  cases  of  sudden  death,  and,  in  the  aljsence  of  a 
laryngoscopic  examination,  would  in  all  probability  have  been 
pronounced  by  a  coroner's  jury  as  due  to  a  "  visitation  of  God."' 
Doubtless  many  cases  of  sudden  death  attributed  to  a  visitation 
of  Providence  have  been  due  to  suffocation  by  a  laryngeal  tumor, 
the  existence  of  which  has  not  been  suspected.  Examinations 
of  the  larynx  in  cases  of  sudden  death  would  throw  light  on  this 
point. 

In  contrast  to  these  cases,  many  others  are  on  record  of  much 
larger  growths,  implicating  the  glottis  to  a  much  more  serious 
extent  in  appearance,  and  also  in  reality,  and  in  which  there 
were  no  severe  symptoms  of  dyspnoea  threatening  suffocation. 

Dysphagia,  or  difficulty  of  swallowing,  is  not  apt  to  be  pre- 
sent unless  the  tumor  is  very  large  so  as  to  encroach  upon  the 
cavity  of  the  pbarynx,  or  unless  the  tumor  occupies  the  epiglot- 
tis or  some  portion  of  the  region  of  the  arytenoid  cartilages, 
or  the  cartilages  of  Santorini. 

Pain  of  an  acute  character  is  unusual  in  growths  in  the 
larynx,  and  when  present  is  usually  due  to  some  other  cause. 
More  or  less  sense  of  annoyance,  however,  is  not  infrequent, 
with  sometimes  a  sensation  as  of  the  presence  of  something 
which  ought  not  to  be  there,  and  a  consequent  disposition  to 
eject  the  foreign  matter  by  expectoration.  Occasionally,  hov\-- 
ever,  severe  paroxysms  of  pain  actually  occur. 

In  addition  to  these  symptoms,  we  occasionally  find  some 
alteration  in  the  external  configuration  of  the  larynx  ;  and  not 
infrequently,  when  the  tumor  is  large  and  of  soft  consistence, 
portions  are  spontaneously  detached,  or  broken  off  during 
paroxysms  of  cough,  and  expectorated. 

Mackenzie  refers  the  formation  of  growths  in  the  larynx  to 


GROWTHS    IN^    THE    LARYNX.  411 

hypersemia,  and  to  catarrh  as  the  most  frequent  cause  of  the 
hyperaemia/  He  states  that  "  neither  syphilis  nor  phthisis,  nor 
any  other  constitutional  condition  appears  to  favor  the  growth  of 
these  neoplasms." "  Indeed,  both  the  diathetic  con- 
ditions referred  to,  appear  to  exercise  a  decidedly  antagonistic 
influence  to  the  development  of  new  formations." 

My  own  experience  differs  very  markedly  from  that  of  the 
author  quoted.  Leaving  out  of  consideration,  as  he  does,  those 
"  imperfect  papillary  growths"  which  "  occasionally  appear  on 
the  posterior  wall  of  the  larynx,  and  on  the  mucous  membrane 
covering  the  vocal  cords  and  the  inner  surface  of  the  arytenoid 
cartilages"  "in  the  latter  stages  of  laryngeal  phthisis  ;"  and  al- 
though I  do  not  find  with  him  that  "  this  is  the  exception," 
but  rather  a  frequent  occurrence,  I  have  met  with  a  large 
proportion  of  cases  in  which  distinctly  formed  growths,  of  cir- 
cumscribed outline,  and  often  of  tolerably  large  size,  existed  in 
cases  of  phthisis  at  a  very  early  stage,  as  well  as  in  cases  where 
the  ravages  of  the  disease  were  readily  detected  on  physical  ex- 
amination of  the  chest ;  and  in  some  of  these  cases  which  have 
terminated  fatally,  and  in  others  which  are  steadily  progressing 
towards  a  fatal  termination,  the  danger  of  impending  suffocation 
has  been  averted,  and  tlie  voice  improved  or  restored  by  intra- 
laryngeal  operations,  arousing  vain  hopes  in  the  patient  of  com- 
plete cure  in  prospect. 

Dr.  Mackenzie  remarks  "  when  a  very  protracted  syphilitic 
congestion  occurs,  growths  may  arise,  but  this  is  a  rare  excep- 
tion;" and  he  quotes  Dr.  Harlan  (J.7w.  Jour.  Med.  Soi.,  vol.  lii. 
p.  122)  as  having  well  pointed  out  that  "  few  laryngeal  growths 
can  be  attributed  to  syphilis."  It  is  undoubtedly  true  that  but 
few  cases  of  syphilitic  congestion  of  the  larynx  give  rise 
to  the  formation  of  growths  ;  but  we  fear  that  both  Dr.  Har- 
lan and  Dr.  Mackenzie  are  mistaken  in  their  inference  that 
few  laryngeal  growths  can  be  attributed  to  syphilis.  In  a  sub- 
joined table  of  sixty-six  cases  occurring  consecutively  in  the 
writer's  private  practice  during  the  last  five  years,  eight  cases 


1  Essay  on  Growths  in  the  Larynx.     London,  1871.     An  eleg-ant  and  classical 
work,  worthy  of  close  study. 


412      affectiojsts  of  the  larynx  and  tkachea. 

were  distinctly  traced  to  syphilitic  congestion  of  the  laryngeal 
strnctnres,  and  twentj^-two  cases  occurred  in  patients  with  phthi- 
sis. It  is  bnt  jnstice  to  Dr.  Mackenzie  to  cpiote  that  he  admits 
that  "  of  course  laryngeal  growths  may  occnr  in  syphilitic  per- 
sons as  they  do  in  the  healthy,  bnt  syphilis  does  not  appear  to 
be  a  factor  in  their  production."  Syphilis  is  a  disease  of  such 
vast  extent,  of  such  remorseless  influence  upon  physiological  and 
pathological  conditions  generally,  that  it  is  not  improper  to  refer 
all  cases  of  growth  in  syphilitic  individuals  to  that  cause 
wherever  there  is  anything  like  a  clear  history  ;  whenever  there 
is  other  evidence  of  syphilitic  disease  ;  and  to  suspect  a  syphi- 
litic origin  whenever  there  is  no  other  assignable  cause,  in  a 
patient  who  has  already  suffered  from  syphilitic  poisoning,  especi- 
ally if  his  remoter  symptoms  have  been  observable  in  his  throat. 

It  is  extremely  difficult  to  trace  the  origin  of  these  forma- 
tions. Patients  usually  attribute  them  to  "  colds."  They  ap- 
pear to  take  their  departure,  whatever  be  the  predisposing 
canse,  from  catai-rhs ;  syphilitic  and  tuberculous  sore  throat ; 
erysipelas  ;  the  exanthemata,  particularly  measles  ;  exudative 
inflammation  of  the  larynx,  whether  croupal  or  diphtheritic  ; 
whooping-cough  ;  and  the  inhalation  of  irritating  substances, 
whether  in  solid  or  gaseous  form. 

Growths  in  the  larynx  appear  at  all  ages.  Some  are  congen- 
ital, and  others  make  their  appearance  in  advanced  life.  My 
own  experience  includes  cases  apparently  congenital,  and  one 
occurring  at  upwards  of  80  years.  They  occur  of  course  in 
both  sexes,  but  most  frequently  in  the  male.  The  periods  of 
life  at  which  they  have  been  observed  most  frequently  vary 
perhaps  between  25  and  45  years  of  age. 

Tumors  of  all  kinds  have  been  observed  in  the  larynx,  the 
most  frequent  variety  being  papillomata.  In  Dr.  Mackenzie's 
tabulated  list  of  one  hundred  cases  of  benign  laryngeal  growths 
subjected  to  treatment,  sixty-seven  were  judged  to  be  of  this 
character.  Of  sixty-six  cases  of  growth  of  all  kinds,  benign 
and  malignant,  in  my  own  list,  forty-eight  were  supposed  to  be 
papillomata.  The  results  of  the  observations  of  other  authors 
do  not  differ  materially  from  those  of  Dr.  Mackenzie. 

The  papillomatous  growths  are  frequently  multiple.      The 


GKOWTHS  IN  THE  LAEYNX.  413 

other  formations  are  usually  single.  Fibroid  tumors,  simple 
and  recurrent ;  mucous  or  cystic  tumors,  fatty  tumors,  glandu- 
lar tumors,  vascular  tumors,  epithelial  and  cancerous  tumors 
have  been  found  in  the  larynx  by  diiferent  obserN'ers ;  and  in 
some  instances  the  growths  have  exhibited  unmistakable  evi- 
dences of  being  compound,  or  composed  of  more  than  a  single 
form  of  tissue. 

The  papillomatous  growths,  occurring  in  cases  of  plithisis, 
are  apt  to  recur,  but  this  does  not  appear  to  be  the  case  when 
there  is  no  constitutional  disease.  The  malignant  growths,  as  a 
matter  of  course,  are  exceedingly  apt  to  recur.  The  most  re- 
markable instance  of  this  kind,  of  which  I  have  any  knowledge, 
is  the  following : 

A.  E.,  merchant,  aged  fifty-six  years,  a  resident  of  ISTew 
.  York,  applied  to  me,  January  15th,  1S71,  at  the  office  of  Dr. 
Elsberg  (to  see  whose  patients,  I  made  periodical  visits  to  New 
York  during  his  absence  in  Europe),  on  account  of  a  laryngeal 
trouble,  of  long  standing,  which  was  giving  him  some  recent 
annoyance-  He  stated  that  some  four  months  previously.  Prof, 
von  Bruns,  of  Tubingen,  had  removed  a  large  polyp  from 
his  larynx  by  means  of  the  ecraseur,  tracheotomy  having  been 
performed  previously.  On  examination  I  found  a  large 
polyp,  the  size  of  half  a  cherry,  lying  upon  the  vocal  cofds  an- 
teriorly, and  attached  on  the  left  side.  Two  very  small  growths 
were  seen  to  the  left  of  this  and  below.  The  patient  w^as  very 
much  concerned  when  I  told  him  of  the  presence  of  the  growth, 
and  still  more  so  w-hen  I  advised  him  to  have  it  removed  at  once 
by  operation  externally.  He  w^as  very  anxious  to  have  it  re- 
moved by  the  ecraseur,  the  same  way  as  had  been  done  by  Prof, 
von  Bruns,  but  this  was  represented  to  him  as  insufficient,  on 
account  of  the  great  liability  to  further  recurrence  ;  and  the  ex- 
ternal operation  was  urged  upon  him  as  the  best  means  of  sav- 
ing his  life.  I  made  one  attempt  to  seize  the  growth  with 
forceps,  but  was  unsuccessful,  and  did  not  press  the  matter  fur- 
ther, inasmuch  as  it  was  thought  best  not  to  interfere  with  it 
except  for  thorough  removal.  The  patient  left  after  making 
an  appointment  for  another  interview,  but  did  not  return  to 
keep  it. 


414     ArFECTio:s's  of  the  laeynx  ais^d  teachea. 

Some  months  afterwards  I  found  on  Dr.  Elsberg's  table  a 
pamphlet/  recently  published  by  Dr.  Huppaner,  of  'Nesv  York, 
in  pernsiug  which  I  learned  the  subsequent  history  of  this  case. 

It  appears  that  Mr.  E.  first  consulted  Dr.  Ruj^paner  about  a 
month  after  I  saw  him,  at  which  time  the  growth  filled  "  nearly 
the  entire  supra-glottic  space  of  the  large  larynx  of  the  patient." 
Dr.  Ruppaner  subsequently,  on  May  8th,  removed  the  growth  by 
thyrotoni}',  after  the  previous  performance  of  laryngo-tracheo- 
tomy,  and  found  that  it  weighed  113  grains,  and  was  a  fibro- 
sarcoma. The  rapid  growth  of  this  tumor  from  the  size  of  half 
a  cherry  on  January  15th,  to  such  a  mass  as  nearly  to  fill  the 
supra-glottic  space  by  the  13th  of  February  following,  certainly 
renders  it  the  most  remarkable  case  of  rapid  laryngeal  growth 
on  record. 

A  very  curious  morl)id  growth  of  the  larynx,  occasionally  met 
with,  consists  of  a  band  of  membrane  stretching  from  one  vocal 
cord  to  another.  I  have  seen  two  instances  of  the  kind,  and  both 
in  females  suffering  Avith  phthisis.  One  case  was  under  my  own 
care,  and  was  seen  in  consultation  by  Dr.  Elsberg  of  iSew  York ; 
the  formation  being  of  recent  origin,  and  apparently  subsequent 
to  ulceration  of  the  vocal  cords.  The  other  case  occurred  in  the 
practice  of  Dr.  Elsberg,  and  has  been  reported  by  him  in  the 
Transactions  of  the  American  Medical  Association  for  1870. 
Here  the  bridge  was  exceedingly  large,  and  was  supposed  to 
have  been  congenital.  It  was  divided  by  the  knife  with  relief 
to  insufficiency  of  respiration,  so  marked,  that  the  patient,  a 
stunted  girl  of  some  16  or  17  years  of  age,  acquired  a  normal 
stature  in  a  few  months.  Tlic  voice  became  good,  though  shrill. 
During  an  illness  of  Dr.  Elsberg  I  had  occasion  to  perform  a 
second  operation.  The  anterior  portion  of  the  commissure  shows 
marked  disposition  to  reunite,  and  its  division  with  the  galvano- 
cautery,  or  a  plastic  operation  practised  after  division  of  the  thy- 
roid cartilage,  may  become  necessar}^  to  overcome  the  difficulty. 

The  size  of  a  growth  in  the  larynx  will  vary  from  that  of  a 
small  seed  to  that  of  a  mass  almost  filling  the  laryngeal  cavity, 
and  projecting  beyond  its  lateral  borders. 


1  Contributions  to  Practical  Laryngoscopy.     Second  Series.     Illustrated. 


GROWTHS    IlSr    THE    LAETNX.  415 

Morbid  growths  may  occupy  any  portion  of  tlie  larynx,  but 
their  most  frequent  seat  is  upon  the  vocal  cords,  a  curious  cir- 
cumstance as  yet  unaccounted  for.  When  we  reflect  that  these 
structures  are  in  constant  motion,  we  might  suppose  on  the  one 
hand  that  this  would  be  antagonistic  to  the  development  of  a 
growth  ;  or,  on  tlie  other,  that  this  very  activity  would  keep  up 
a  vascular  supply  of  materials  for  its  development  once  the 
morbid  action  has  become  established.  That  the  activity  of  the 
vocal  cords  is  not  antagonistic  to  the  formation  of  morbid 
growths,  is  known  by  actual  experience. 

The  subjoined  table  gives  the  nature  and  seat  of  sixty-six 
cases  of  morbid  growths  in  the  larynx  that  have  come  under  the 
author's  professional  observation,  in  his  own  practice. 

Thirty-one  Cases  without  apparent  Constitutional  Disturlance. 

9  cases  of  papillomata  (3  multiple)  on  one  vocal  cord. 

6     "  "  (2         "      )  on  both   "  cords. 

3     "  "  beneath    "     " 

1  case  '       "  on  both    "     "      and  both  ventricular  bands. 

1     "  "  "      "       "     "     and  posterior  wall  of  larynx. 

1     "  "  a      ii       u     1.1.     and  one  arytenoid  cartilage. 

1  "  "  in.  left  ventricle. 

2  cases  "  on  left  aryteno-epiglottic  fold. 

3  "  "  "  epiglottis. 

1  case  "  1 1         u  ^j^^  Yeit  aryteno-epiglottic  fold. 

1  "         of  iibroid  polyp  (pedunculated)  beneath  one  vocal  cord. 

2  cases  of  epithelioma  upon  both  vocal  cords. 

Ticenty-tvjo  Cases  associated  loith  Phthisis. 

4  cases  of  papilloma  (3  multiple)  on  one  vocal  cord. 
"       )  "  both    "     cords. 

"  both  ventricular  bands,  and  posterior  wall. 

"  posterior  wall  of  larynx. 

"         "  "  "  and  both  ventricles. 

"  one  ventricular  band  (left).  , 

"  epiglottis. 

"  one  cord. 

1.1        u  u 

"  both  cords  and  both  ventricles. 

' '  epiglottis,  one  vent,  band,  one  vocal  cord. 

"  both  vocal  cords. 
2  cases  of  cystic  (refilling  in  a  few  months)  on  both  arytenoids. 
2     "  membranous  bands  on  both  cords,  stretching  from  one  to  the  other 

anteriorly. 


3     " 

It                  /O 

1  case 

" 

1     " 

u 

1     " 

1     " 

11. 

2  cases 

"• 

1  case 

fibroma 

1     " 

epithelioma 

1     " 

" 

1     " 

u 

1      " 

trachoma 

416  AFFECTIONS    OF   THE    LAEYISTX. 

Eight  Cases  associated  with. Syj)hilis. 

4  cases  of  papilloma  (1  multiple)  on  both  vocal  cords. 
1  case  "  "  one       "     cord. 

1     '•  '«  "  epiglottis,  and  both  ventricular  bands, 

-1         u  u  u  >'  '>•  "  " 

and  both  vocal  cords. 
1     "         spindle- celled  sarcoma  "  both  ventricles,  both  arytenoid  cartilages, 

and  posterior  wall  of  cricoid. 


Five  Cases  of  Malignant  Grov)ths. 

1  case  of  fibro-sarcoma  on  one  vocal  cord. 

1  "        encephaloid      "  epiglottis,  and  right  ventricular  band. 

2  cases    epithelioma      "  epiglottis. 

1  case  "  filling  entire  larynx. 

The  microscopic  examinations  in  the  above  cases,  with  the 
exception  of  a  number  which,  being  j  tidged  of  as  papillomata  by 
external  appearance,  were  not  submitted  to  microscopic  exami- 
nation, were  made  by  Dr.  J.  J.  Woodward  of  Washington,  and 
Drs.  Da  Costa,  Pancoast,  Jr.,  Tyson,  Wm.  Pepper,  and  Corbit 

Note. — Since  the  above  list  has  been  in  the  hands  of  the  printer  the  author 
has  had  five  more  cases;  one,  a  cystic  tumor  of  the  lingual  face  of  the  epi- 
glottis, in  a  lady  in  good  health,  but  troubled  with  sore  throat  (attributed  to 
chronic  pharyngitis)  for  more  than  fifteen  years  ;  she  declines  interference  for 
the  present.  The  second  case  concerns  a  number  of  papUlomata  in  a  married 
lady,  about  forty  years  of  age  ;  the  growths  occupied  the  edges  of  the  vocal 
cords  and  the  posterior  wall  of  the  larynx,  and  produced  great  dyspnoea. 
They  are  attributed  to  syphilis,  though  no  distinct  history  of  this  kind  can  be 
obtained.  They  were  readily  removed  with  the  forceps,  but  show  an  unusual 
disposition  to  recur,  a  circumstance  pointing  to  tuberculosis,  perhaps,  rather 
than  syphilis.  As  yet,  no  malignant  elements  have  been  detected  under  the 
microscope.  The  third  case  is  one  of  phthisis  in  its  early  stage,  without 
marked  auscultatory  corroborative  evidence,  and  is  in  the  form  of  a  fimbriated 
papillomatous  mass  upon  the  inner  surface  of  one  of  the  arytenoid  cartilages, 
as  usual  the  left  one,  and  is  attended  with  considerable  ialiammatory  swelling 
of  the  cartilage,  suggestive  of  perichondritis  ;  the  parts  are  so  irritable  that 
the  growth  cannot  be  grasped  in  the  forceps,  and  systematic  manipulations  are 
paving  the  way  for  its  removal,  which  is  indicated  on  account  of  occasional 
paroxysms  of  dyspnoea.  The  fourth  case  is  one  of  multiple  tumors  on  pos- 
terior laryngeal  wall,  with  complete  aphonia.  Phthisis  suspected.  The  fifth, 
a  whitish  tumor,  nature  undetermined,  in  the  substance  of  the  left  vocal  cord, 
and  on  its  inferior  face.     Phthisis  suspected. 


TEEATMENT  OF  GROWTHS  IIST  LARYNX.      417 

of  Philadelphia,  all  of  whom  are  acknowledged  to  be  compe- 
tent microscopists. 

The  diagnosis  of  growths  in  the  larynx  may,  nnder  certain 
favorable  circumstances,  be  assisted  by  physical  exploration 
with  the  end  of  the  finger  ;  but  even  when  the  growths  are  high 
up  and  very  large,  merely  a  vague  notion  can  be  thus  obtained. 
The  only  method  of  arriving  at  a  satisfactory  diagnosis  as  to  the 
existence  of  a  tumor,  its  seat,  mode  of  attachment,  size,  etc.,  is 
by  laryngoscopic  examination.  The  entire  extent  of  growth 
cannot  always  be  inspected  in  this  way,  but  much  valuable  infor- 
mation on  this  point,  as  well  as  with  reference  to  the  consistence 
of  the  growth,  its  movability,  and  the  feasibility  of  its  removal 
through  the  month,  may  be  obtained  by  examining  it  with  a  bent 
probe  or  laryngeal  sound,  applied  with  the  aid  of  the  laryngo- 
scopic mirror.  The  accomplishment  of  this  exploration  is  not 
accompanied  by  much  difficulty,  inasmuch  as  the  parts  have 
usually  been  already  rendered  somewhat  tolerant  of  mechanical 
manipulation  by  the  very  presence  of  the  tumor. 

Treatment  of  Growths  in  the  Larynx — There  is  no  doubt 
of  the  f5,ct,  that  some  growths  in  the  larynx  are  susceptible  of 
spontaneous  cure ;  but  such  a  fortunate  result  occurs  but  seldom, 
and  cannot  be  foretold  beforehand. 

Certain  growths  of  syphilitic  origin,  arising  in  part,  if  not  in 
whole,  from  the  cicatrizing  surface  of  ulcers,  even  when  quite 
fleshy  or  sarcomatous  in  appearance,  will  gradually  yield  to  in- 
ternal treatment  by  iodide  of  potassium  and  bichloride  of 
mercury ;  and  in  cases  of  this  kind  where  the  growths  are  not 
large,  and  do  not  interfere  with  the  respiratory  functions,  it  is 
well  to  give  a  fair  opportunity  to  this  treatment  before  resorting 
to  operative  procedures.  Even  in  cases  of  comparatively  large 
growths,  compromising  the  function  of  respiration,  it  would  not 
be  inadvisable,  if  concomitant  indications  are  favorable,  to  per- 
form tracheotomy  in  order  to  overcome  the  dyspnoea,  and  to 
await  the  result  of  internal  treatment  before  instituting  local 
interference.  Such  cases  should  be  watched  most  assiduously 
with  the  laryngoscopic  mirror,  as  a  matter  of  course,  in  order  to 
study  the  progression  or  retrogression  of  the  growths. 


418        ABTECTIOJSrS    OF    THE    LAETNX   AND    TRACHEA. 

As  a  rule,  however,  an  operative  procedure  is  requisite  in 
most  cases  of  laryngeal  growths,  eitlier  for  their  removal  by  for- 
ceps or  cutting  instruments,  or  for  their  destruction  by  caustics 
or  crushing  instruments. 

Where  the  growth  is  small,  and  does  not  interfere  with  the 
function  of  resj)iration,  there  is  no  necessity  for  surgical  inter- 
vention, except  in  cases  of  interference  with  the  voice  in  indi- 
viduals who  gain  their  livelihood  by  singing  or  sj)eaking.  In  a 
private  individual,  to  whom  a  moderate  degree  of  hoarseness  is  of 
no  account,  a  small  growth  need  not  be  subjected  to  treatment  un- 
less repeated  laryngoscoj)ic  examinations  show  that  it  is  increas- 
ing in  size.  Under  these  circumstances  there  can  be  no  doubt  as 
to  the  propriety  of  its  removal.  Cases  are  on  record  where  small 
growths  have  remained  stationary  for  long  numbers  of  years.  I 
have  examined  the  larynx  of  a  lady  from  time  to  time,  in  whom  a 
small  growth  on  one  of  the  vocal  cords  has  remained  unchanged 
for  at  least  ten  years,  presenting  the  same  appearance  as  first  seen 
when  originally  examined  by  Dr.  Elsberg,  of  New  Tork,  as  to  the 
cause  of  a  hoarseness  of  voice  which  had  then  existed  for  some 
sixteen  years.  It  is  the  case  depicted  in  Fig.  26,  in  his  prize  essay.' 
On  one  occasion,  recently,  after  catching  cold,  the  little  nadule  on 
the  right  vocal  cord  had  acquired  a  tapering  end,  which,  in 
phonation,  struck  the  opposite  cord,  and  produced  increased 
hoarseness,  and  a  troublesome  sensation  in  the  parts  ;  but  shortly 
afterwards  the  parts  resumed  their  ordinary  appearance. 

A  case  will  be  narrated,  in  the  sequel,  in  which  an  elderly 
gentleman  had  probably  had  a  growth  since  childhood,  and 
which,  becoming  enlarged  so  as  to  produce  distressing  hoarse- 
ness, was  destroyed  by  a  single  application  of  the  acid  nitrate  of 
mercury. 

The  operations  performed  for  the  removal  of  growths  within 
the  larynx  consist  in  cauterization  ;  crushing  with  the  forceps ; 
extraction  by  the  forceps,  or  by  the  wire  loop,  or  a  small  chain 
ecraseur;  scarification  and  cauterization ;  excision  with  the  knife, 
scissors,  or  the  galvano-cautery ;  and  removal  after  section  of  the 
thyroid  cartilage. 

'  Laryngoscopal  Surgery  illustrated  in  the  Treatment  of  Morbid  Growths 
within  the  Larynx.  Prize  Essay  of  the  American  Medical  Association  for  1865 


TEEATMENT    OF    GROWTHS    IN    LAETNX.  419 

Removal  after  sub-hyoidean  laryngotomy,  lias  been  performed 
by  Dr.  Pratt/  in  1859,  and  subsequently,  in  1863,  by  Dr.  Follin,' 
but  it  is  not  likely  that  this  operation  will  ever  now  become 
legitimized  in  surgery,  because,  as  Dr.  Mackenzie  remarks,  the 
cases  most  suitable  for  it  are  just  those  which  can  be  most  rea- 
dily reached  through  the  mouth  by  laryngoscopic  treatment. 

Small  condylomatous  tumors,  papillomata  as  they  are  called, 
and  which  are  frequently  multiple,  may  often  be  destroyed  by 
repeated  applications  of  caustics,  such  as  nitrate  of  silver,  chlo- 
ride of  zinc,  chromic  acid,  nitric  acid,  acid  nitrate  of  mercury, 
Vienna  paste,  etc.  Growths,  even  of  considerable  size,  are 
sometimes  amenable  to  this  treatment,  though,  as  a  rule,  it  is 
better  under  such  circumstances  to  remove  as  much  as  possible 
with  the  forceps,  and  then  to  cautei'ize  the  remnant  of  the 
growth. 

For  the  purpose  of  conveying  the  caustic  material  to  the  parts, 
various  instruments  have  been  devised ;  most  of  them  shielded 
so  as  to  prevent  contact  of  the  substance  with  the  sound  tissues. 
To  enter  into  a  description  of  all  the  instruments  which  have 
been  constructed  for  this  purpose,  and  for  other  purposes  of 
laryngeal  surgery,  and  to  discuss  their  merits,  would  be  a  task 
as  thankless  as  it  is  unnecessary.  All  that  will  be  attempted  in 
these  pages  will  be  to  describe  those  instruments  which  are 
really  valuable,  and  which  have  withstood  the  test  of  experi- 
ence ;  and  this  remark  refers  to  the  whole  subject  of  laryngeal 
surgery  as  well  as  to  that  under  immediate  discussion. 

In  order  to  be  effective,  the  caustic  must  be  used  in  concen- 
trated solution  or  in  substance,  and  must  be  kept  in  contact 
with  the  morbid  structure  for  some  seconds,  as  a  mere  momen- 
tary touching  will  prove  ineffective.  The  parts  are  treated  in 
this  manner  every  day,  or  every  other  day,  or  less  frequently 
according  to  circumstances;  and  these  must  be  judged  of  in 
individual  cases,  according  to  results.  As  a  rule,  the  first  con- 
tact of  a  caustic  solution  with  any  portion  of  the  larynx  induces 
a  distressing  spasm,  which  becomes  less  and  less  as  the  parts 

1  Gazette  des  Hopitaux,  1859,  No.  103,  p.  409.     Elsberg's  Prize  Essay,  p.  15. 
^  Mackenzie  on  Laryngeal  Growths,  p.  99,  from  ArcJi.  Gen.  de  Med.,  Feb., 
1867. 


420        AFFECTIOIS^S    OF    THE    LAEYISTX    AND    TRACHEA. 

become  accustomed  to  the  interference.  It  is  well,  therefore, 
to  test  the  sensibility  of  the  parts  beforehand  bj  the  employment 
of  moderate  measures  before  resorting  to  severe  ones.  Prof. 
Stromeyer  tells  us  that  several  patients  have  lost  their  lives  in 
the  surgeon's  office  by  incautious  cauterization  of  the  larynx. 

Operations  of  this  kind,  therefore,  and  in  fact  all  intra-laryn- 
geal  operations,  should  not  be  undertaken  until  the  sm-gebn  has, 
by  repeated  practise  in  minor  cases  of  laryngeal  disease,  acquired 
the  skill  to  carry  his  instrument  safely  to  the  desired  point. 
Fortunately,  sound  tissues  bear  the  contact  of  the  ordinary  caus- 
tics very  well,  and  but  little  injury  ensues  if  they  are  cauterized 
instead  of  the  growth  ;  but  this  does  not  affect  the  growth  which 
has  not  been  reached. 

As  a  rule,  the  morbid  growth  itself  is  much  less  sensitive 
than  the  sound  portions  of  the  larynx,  and  therefore  if  the  pa- 
tient is  steady  and  the  operator  skilled,  there  is  less  danger  of 
inducing  suffocative  paroxysms  than  might  otherwise  be  sup- 
posed. 

In  my  own  hands  this  treatment  is  reserved  for  very  small 
growths  which  I  cannot  get  hold  of  with  the  forceps  or  other 
instrument  for  removal  or  extraction,  and  for  exciting  destruc- 
tive action  in  the  remnants  of  larger  growths,  as  much  of  which 
as  possible  has  already  been  removed  by  some  of  the  methods 
to  be  described  later. 

Concentrated  solutions  of  caustic  materials  are  best  applied 
by  means  of  small  pieces  of  sponge  securely  fastened  to  slender 
but  strong  and  rigid  wires,  or  firmly  held  between  the  teeth  of 
delicate  forceps.  The  following  illustrations  will  serve  to  give 
a  better  idea  of  these  instruments  than  an  elaborate  description. 

The  fused  nitrate  of  silver  in  stick  may  be  applied  by  means 
of  special  caustic-holders,  of  which  many  forms  have  been  con- 
trived by  Lewin,  Fauvel,  Bruns,  Elsberg,  and  others,  or  by 
means  of  the  forceps-holder  of  Tobold,  depicted  in  Fig.  76. 
But  all  instruments  of  this  kind  are  clumsy,  and  conceal  the 
essential  point  of  the  instrument  from  view.  A  much  better 
method  is  that  of  dipping  a  roughened  platinum  bulb  into 
melted  caustic,  after  first  heating  the  bulb,  which  will  enable  it 
to  take  up  sufficient  of  the  material  and  to  hold  on  to  it  for 


TREATMENT    OF    GROWTHS    IIST   LARYISTX. 


421 


many  hours.  Tobold's  probe  is  depicted  in  Fig.  77,  and  answers 
an  admirable  purpose  when  the  growth  is  small.  Dr.  Mac- 
kenzie prefers  an  aluminium  wire  for  this  purpose,  and  Prof. 
Stromejer  recommends  a  metallic  sound  with  a  glass  bulb  sol- 


Fig.  73 


Tobold's  Sponge-holder  (after  Tobold). 


Sponge-holder. 


dered  on  it,  the  bulb  to  be  immersed  in  a  concentrated  solution 
of  nitrate  of  silver,  which  is  then  allowed  to  dry  upon  it. 

Prof.  Tobold  has  also  devised  a  concealed  socket,  movable 
in  any  direction,  in  which  the  molten  nitrate  of  silver,  or  chromic 


422     AFFPXTioisrs  of  the  laeynx  and  trachea. 

Fig.  75. 


Fig.  76. 


Elsberg'g  Sponge-holcier. 


Fig.  77. 


Tobold's  Forceps  for  nitrate  of 
silver  in  stick  (Tobold). 


Tobold's  Roughened  Probe,  for  the  us9 

of  molten  nitrate  of  silver  (Tobold). 


acid  crystals,  if  preferred,  can  be  inserted,  and  which  is  pushed 
forward  at  the  desired  moment  to  expose  the  caustic.  It  is  de- 
picted in  Fig.  78. 


TREATMENT    OF    GROWTHS    IN    LAEYNX.  423 

The  escliarotic  employed  most  frequently  by  Dr.  Mackenzie, 
of  London,  is  the  London  paste,  already  mentioned  in  connec- 
tion with  that  gentleman's  method  of  treating  enlarged  tonsils. 

Fig.  78. 


Tobold's  Concealed  Holder,  for  molten  nitrate  of  silver,  or  for  chromic  acid  (Tobold). 

The  following  illustrations,  Figs.  Y9  and  80,  will  represent 
the  sort  of  growths  treated  by  the  author  with  caustics. 

Fig.  79  represents  the  appearance  of  a  growth  upon  the  left 
vocal  cord  of  a  gentleman  aged  about  sixty  years,  who  had  been 
hoarse  from  childhood :  but  in  whom  the  hoarseness  had  in- 


424       AFFECTIONS    OF    THE    LAEYJSTX    AIS'D    TRACHEA. 

creased  very  much  during  four  or  live  months  previous  to  his 
application  to  me  for  relief.  I  found  a  small  warty  excrescence 
occupying  the  anterior  portion  of  the  left  vocal  cord,  and  in 
such  a  position  as  to  interfere  seriously  with  vocalization.  The 
voice  was  always  hoarse,  but  would  become  suddenly  aphonic 
in  the  midst  of  a  sentence,  and  then  after  a  clearing  of  the 
throat  by  cough,  revert  to  its  former  hoarseness.  The  annoy- 
ance of  this  inconvenience,  the  existence  of  a  harassing  cough,  and 
the  dread  of  some  fearful  result,  rendered  the  patient  anxious 
for  relief.  I  attempted  to  remove  the  growth  with  the  forceps  ; 
but  during  repeated  efforts  only  succeeded  in  detaching  an  in- 
significant portion  of  it.     Finding   no   beneficial   result  fi'om 

Fig.  79.  .  Fig.  80. 


Excrescence  on  left  vocal  cord,  j  Excrescence  on  right  vocal  cord. 

nitrate  of  silver,  and  being  unwilling  to  open  the  larynx  for  the 
removal  of  a  growth  which  was  not  interfering  with  respiration, 
I  finally  concluded,  by  the  advice  of  a  professional  friend  called 
in  consultation,  to  attempt  its  destruction  by  the  strong  acid 
nitrate  of  mercury.  Inasmuch  as  the  patient  had  borne  re- 
peated applications  of  the  molten  nitrate  of  silver  with  little  in- 
convenience, I  had  no  hesitation  in  resorting  to  the  agent  men- 
tioned. Iso  difiiculty  was  experienced  in  touching  the  spot ;  but 
there  ensued  the  most  violent  spasm  of  suffocation  that  it  has 
ever  been  my  lot  to  witness  from  the  application  of  a  caustic 
solution  within  the  larynx.  For  a  moment  I  thought  I  had  be- 
fore me  one  of  those  unfortunate  cases  alluded  to  by  Prof, 
Stromeyer,  and  actually  had  my  hand  upon  my  penknife  with 
a  view  of  plunging  it  into  the  trachea,  should  the  spasm  con- 
tinue a  few  moments  longer,  when  the  paroxysm  ceased,  to  my 
unutterable  relief.  After  one  or  two  less  violent  paroxysms  the 
immediate  danger  was  over,  and  I  mentally  resolved  that  I  would 
not  use  the  acid  nitrate  of  mercury  again  under  similar  circuni- 


TREATMENT    OF    GEOWTHS    IIST   LAETNX. 


425 


stances.  The  patient's  voice  was  aphonic  for  several  days, 
during  which  there  was  a  violent  inflammation  of  the  larynx, 
paroxysms  of  asthmatic  dyspnoea,  and  more  or  less  painf  nl  deglu- 
tition. Eest,  purging,  liquid  diet,  and  the  frequent  inhalation 
of  steam  impregnated  with  narcotics,  constituted  the  treatment 
for  this  condition.  The  tumor  sloughed  off,  and  the  patient's 
voice  became  better  than  it  had  been  for  years.  After  his  re- 
covery the  patient  told  me  that  I  should  not  make  another  such 
application,  even  if  it  should  be  the  only  method  of  saving  his 
life.     He  has   had  no  return  of  his  former  trouble. 

Fig.  80  represents  the  larynx  of  a  lady,  thirty-two  j'ears  of 
age,  sent  to  me  by  Prof.  Flagg,  on  account  of  a  persistent 
hoarseness,  of  some  five  or  six  months'  duration.  There  was  no 
cough,  expectoration,  pain,  or  dyspnoea ;  but  the  patient  com- 
plained of  an  occasional  sensation  of  something  in  the  throat 
which  she  would  like  to  get  rid  of.  On  laryngoscopic  exami- 
nation, a  small  gelatinous-looking  mass  was  seen  upon  the  right 
vocal  cord,  which,  on  probing,  proved  to  be  a  morbid  growth. 
It  was  repeatedly  cauterized  with  the  solid  nitrate  of  silver, 
two  or  three  times  a  week,  and  in  less  than  a  month  was  com- 
pletely removed  by  the  treatment,  the  voice  having  recovered 
its  orio-inal  clearness. 


Kg.  81. 


Fig.  82. 


Epithelial  growths  on  both  vocal  cords, 
in  a  case  of  phthisis. 


Appearance  of  cords  after  destruction 
of  growths  with  chromic  acid. 


These  two  cases  are  selected,  the  one  to  show  that  the  ele- 
ment of  danger  in  severe  applications  is  not  always  removed  by 
tolerance  to  measui^es  less  severe ;  and  the  other  to  show  how 
readily  a  soft  growth  of  recent  occurrence  sometimes  yields  to 
the  nitrate  of  silver.     Figs.  81  and  82  represent  the  appearances 


426        AFFECTIOlSrS    OF    THE    LARYNX    AND    TRACHEA. 

of  tlie  larynx  before  treatment  in  a  case  of  epithelial  growths, 
and  after  their  destruction  by  chromic  acid.  These  occurred  in 
a  case  of  phthisis. 

The  treatment  by  the  nitrate  of  silver  is  very  protracted  as  a 
rule.  In  one  of  my  cases,  a  lady  sent  me  by  Dr.  Hall  of  Phila- 
delphia, there  was  complete  aphonia  of  more  than  a  year's  dura- 
tion. Several  minute  growths  occupied  both  vocal  cords.  I 
found  it  impossible  to  grasp  them  in  the  forceps,  and  resorted  to 
nitrate  of  silver.  Applications  were  made  every  two  or  three 
daj^s  for  several  months,  with  occasional  intervals  of  a  week  or 
two  to  see  if  the  growths  would  recede  without  further  treatment ; 
and  at  the  end  of  some  five  or  six  months,  the  cords  were  clear, 
and  the  voice,  which  had  improved  from  the  very  first,  sufficiently 
sonorous  for  all  practical  purposes,  but  not  clear  enough  for 
purposes  of  singing.  Several  years  have  elapsed  and  the  voice 
continues  good. 

In  another  case  the  subject  was  a  prominent  female  vocalist, 
who  applied  to  me  in  the  winter  of  1867  on  account  of  a  diffi- 
culty in  singing  and  occasional  hoarseness,  and  in  whom  I  was 
able  to  watch  the  formation  of  the  growth  as  well  as  its  gradual  re- 
trocession. Laryngoscopic  examination  showed  a  want  of  power 
in  the  muscles  of  the  left  vocal  cord.  As  soon  as  the  lady 
would  exert  her  voice,  the  cord  bent  in  the  middle  so  as  to  de- 
stroy the  elliptical  figure  of  the  opening  of  the  glottis  in  phona- 
tion.  I  told  her  she  must  give  up  singing,  and  rest  the  parts. 
This  she  could  not  do,  being  under  engagement,  but  she  promised 
to  follow  my  advice  in  other  matters,  and  to  obey  me  in  all  as 
soon  as  her  engagement  was  concluded.  She  visited  me  every 
day,  and  I  employed  local  electrization  by  the  induced  current, 
with  the  negative  pole  ajDplied  to  the  cord  by  means  of  Mac- 
kenzie's laryngeal  electrode,  the  positive  pole  being  placed  in 
front  of  the  crico-thyroid  membrane  by  means  of  a  sponge. 
This  treatment  improved  the  voice  for  the  time.  In  a  few 
weeks  the  patient's  duties  required  her  presence  in  another 
city,  and  local  treatment  was  intermitted.  She  continued,  how- 
ever, to  pay  great  attention  to  her  general  secretions,  and  to 
take  three  times  a  day  ten  drops  of  the  compound  tincture 
of  iguatia  aniara,  which  had  been  previously  ordered  for  her- 


TKEATMEISTT    OF    GEOWTHS    IN    LAEYNX.  4:27 

Towards  the  end  of  tlie  winter  she  returned  to  Philadelphia,  the 
voice  much  worse  than  it  had  been  before  she  left.  I  now  noticed 
that  the  bend  of  the  cord  had  become  permanent,  and  that  the 
knuckle  thus  formed  struck  the  opposite  cord  every  time  she 
attempted  to  run  the  scale,  and  that  at  this  point  it  was  eroded  or 
scratched.  The  treatment  by  electricity  was  renewed  without  es- 
sential benefit,  thongh  there  seemed  tobe  some  improvement ;  but 
the  eroded  appearance  upon  the  distorted  cord  became  gradually 
converted  into  that  of  a  knob,  which  finally  developed  itself  into 
a  nodule  the  size  of  the  head  of  a  large  pin.  With  this  I  should 
not  have  felt  inclined  to  interfere  at  the  time,  had  it  not  been 
that  my  patient  was  a  professional  vocalist  dependent  upon  her 
voice  for  her  livelihood,  and  anxious  to  have  her  vocal  powers 
restored  at  any  personal  sacrifice,  rather  than  have  to  support  her- 
self by  instrumental  music,  in  which  she  was  also  a  proficient. 
To  seize  so  small  a  growth  with  a  pair  of  forceps  was  out  of  the 
question.  Several  nnsuccessf  ul  attempts  were  made  to  pierce  its 
base  with  Tobold's  lancet  knife,  and  so  detach  it  from  the  cord. 
Finally  it  was  determined  to  persist  in  the  local  contact  of  the 
molten  nitrate  of  silver  conveyed  npon  a  very  delicate  roughened 
bulb  of  platinum.  The  treatment  was  extremely  protracted. 
Many  times  the  tumor  was  missed  and  the  cord  cauterized  ;  but 
these  persistent  efforts  were  crowned  with  success,  and  finally, 
after  the  patient  had  been  under  my  care  for  two  years,  with 
summer  intermissions,  all  trace  of  disease  was  removed,  and 
after  a  few  months'  practice  to  regain  lost  ground,  the  lady  was 
able  to  sing  with  much  finer  effect  than  she  had  ever  been  able 
to  accomplish  before.  Her  voice  has  remained  perfect  ever 
since. 

The  majority  of  laryngeal  growths  are  suitable  for  removal 
by  evulsion  with  forceps.  Instruments  for  this  purpose  must 
be  slender  and  strong,  and  well  curved.  In  order  to  meet  the 
various  indications  presenting  themselves,  several  pairs  of  for- 
ceps are  required,  of  different  lengths,  and  with  jaws  opening  in 
different  directions.  The  ordinary  form  of  laryngeal  forceps  is 
represented  in  Figs.  83  and  84.  The  jaws  are  provided  with 
teeth,  or  with  serrations,  or  both,  which  hold  on  to  the  growth 
when  it  is  once  grasped,  so  that  it  is  either  removed  in  mass,  or 


428        AFFECTIOIS'S    OF    THE    LAEYI^X   AISTD    TEACHEA. 


in  little  bits,  such  as  are  gouged  out  by  the  jaws  of  the  forceps. 
The  forceps  of  Fauvel,  Fig.  84,  is  provided  with  a  retaining 
catch  on  the  rings,  which  prevents  the  jaws  of  the  forceps  from 
reopening,  once  they  have  grasped  the  growth. 


Fig.  83. 


Fig.  84. 


Tobold's  forceps  (aftxji-  Tobold). 


Fauvel's  forceps. 


A  very  admirable  pair  of  forceps  in  which  the  jaws  open 
only  at  their  extremity  and  thus  do  not  cut  off  a  view  of 
themselves  in  the  laryngoscopic  mirror,  has  been  devised  by 
Dr.  Cuzco,  and  is  represented  in  Fig.  85.     These  I  have  fonnd 


TREA-TMEISTT    OF    GEOWTHS    IN    LARYNX.  429 

very  efficient,  and  very  strong;  and  have  had  them  constrncted 
so  that  the  movable  jaw  opens  anteriorly,  posteriorly,  or  to 
either  side,  in  order  to  facilitate  the  removal  of  growths  situated 
in  different  localities  of  the  larynx. 

Fig.  85. 


Cuzco's  forceps. 

Dr.  Mackenzie  of  London  has  improved  the  laryngeal  forceps 
by  altering  the  cmwe  and  rendering  it  more  abrupt.  With  these 
instruments,  contact  with  the  epiglottis  is,  in  many  cases,  more 
easily  avoided  than  with  instruments  with  the  catheter-like 
curve.  Still  the  latter  are  as  yet  in  more  common  use,  and 
have  done  good  service.  I  have  used  these  forceps  of  Mac- 
kenzie, recently,  with  great  satisfaction.  They  are  depicted  in 
Fig.  86,  and  I  am  indebted  to  the  inventor  for  the  illustration. 

A  peculiar  form  of  forceps,  termed  tube-forceps  by  Mac- 
kenzie, were  early  constructed  by  laryngoscopic  operators. 
The  design  was  to  secure  a  slender  instrument  with  jaws  at 
its  extremity,  which  jaws  could  be  opened  or  closed  at  will  by 
means  of  a  spring  in  the  handle  and  controlled  by  the  operating 
hand.  These  were  constructed  so  that  the  blades  of  the  forceps 
portion  could  present  in  any  desired  direction.  The  German 
laryngoscopists  in  particular  have  been  very  prolific  in  devices  of 
this  kind.  These  instruments  are  not  very  serviceable  except 
in  the  case  of  small  gi'owths ;  and  they  are  exceedingly  liable  to 
get  out  of  order.     The  delicacy  of  their  mechanism  is  incom- 


430        AFFECTIOI^S    OF    THE    LAEYI^X    AKI)    TRACIIEA. 

Fig.  86. 


Mackenzie's  laryngeal  forceps  (Mackenzie). 

A    Lateral  forceps  B.  Anteroposterior  forceps.  C.  Cutting foTceps. 

D.  Forceps,  of  -which  one  blade  cuts,  while  the  other  presents  a  flat  surface. 

patible  with  a  sufficient  degree  of   strength  for  most  purj^ses. 
Still,  in  cases  of  soft  growths,   especially  in    the  immediate 


TEEATMENT    OF    GEOWTHS    Ij^-    LAETISTX. 


431 


vicinity  of  tbe  glottis,  and  beneath  it,  tliey  can  be  employed  on 
account  of  their  slenderness,  when  the  larger  instrnments  can- 
not be  used.  A  very  simple  form  of  forceps  of  this  kind,  the 
blades  of  which  are  protruded  by  pressure  of  the  thumb  down 
upon  a  rod  in  the  barrel  of  the  handle,  as  devised  by  Tobold, 
is  depicted  in  Fig.  87. 

Fig.  87. 


Tobold's  concealed  pincette  (Tobold). 

The   more    complicated  tube-forceps  of  Semeleder,  Stoerk, 
"Lewiiij  and   others,  are  not  as   effective    as    the   tube-forceps 


432        AFFECTIOIS'S    OF    THE    LAEYISTX   AND    TllACHEA. 


rig.  88.    Mackenzie's  laiyiigeal  tube-f  creeps 

and  scissors  (Mackenzie.) 
Sp.  A  spring,    by   pressing  on  which,   the 

tube  is  forced  over  the  base  of  the  forceps. 
6.  A  joint,  at  which  the  different  sized  tubes 

are  applied,  and  the  blades  taken  out  and 

cleaned. 
r.  The  ring,  by  turning  which  the  forceps 

revolves  so  that  the  blades  open  in  any 

direction. 
Sc.  Screw,  for  taking  the  instrument  apart 

for  cleansing  it,  etc. 

1.  The  perpendicular  blades. 

2.  4.  The  horizontal  blades. 

3.  The    scissors,   with    hooks    attached    to 
them. 


devised  by  Br.  Mackenzie,  and  used  with  great  success  by  him 
for  a  number  of  years.  lie  has  laid  me  under  obligations  for  an 
illustration  of  these  forceps  which  are  depicted  in  Fig.  88. 


TREATMENT    OF    GROWTHS    IN    LARYNX. 


433 


Fig.  89  represents  the  larynx  of  a  young  man,  tlie  subject  of 
phthisis,  with  several  papillary  growths  above  and  below  the 
vocal  cords.  There  was  great  dyspnoea  and  hoarseness.  The 
growths  were  in  the  main  removed  with  Mackenzie's  tube  for- 
ceps, with  relief  to  the  dyspnoea  and  improvement  in  the  voice. 

Fig,  90  represents  the  larynx  of  a  married  lady  who  had  suf- 
fered for  four  years  with  hoarseness  which  gradually  increased  to 
aphonia  ;  and,  for  a  year  or  so,  with  dyspncea.     The  ventricular 

Fig.  89. 


Papillary  growths  in  phthisis. 
Removed  with  forceps. 


Papilloma  oocup3'iiig  posterior  laryngeal 
wall,  and  removed  by  evulsion. 


bands  were  very  thick  and  hypertrophied,  the  true  cords  were 
barely  seen,  and  a  papillomatous  tumor  of  the  size  of  a  small 
cherry,  or  a  very  large  pea,  occupied  the  postei-ior  wall  of  the 
larynx  below  the  iiiter-arytenoidal  fold.  The  growth  was  re- 
moved by  evulsion  with  Mackenzie's  antero-posterior  forceps, 
with  prompt  relief  to  the  dyspnoea,  and  gradual  restoration  of 
voice. 

When  a  growth  is  pedunculated,  it  can  be  very  readily  removed 
by  a  tug  with  the  forceps,  very  little  force  being  required,  as  a 
rule,  for  this  purpose.     Figs.  91  and  92  represent  growths  of 


Fig.  91. 


Fig.  92. 


Pednncnlated  polyp  on  vocal 
cord,  in  a  case  of  phthisis. 


Pedunculated  fibroid  polj-p  beneath 
vocal  cords,  and  removed  with 
Fauvel's  forceps. 


this  character.     That  depicted  in  Fig.  91  represents  a  peduncu- 
lated growth  on  the  left  vocal  cord  of  a  gentleman  in  the  last 
28 


434 


AFEECTIOlSrS    OF   THE   LAETJSTX   AIS^D    TEACHEA. 


stage  of  phthisis  puhnonalis,  and  brother  of  a  physician  practis- 
ing in  Philadelphia.  The  condition  of  the  patient  rendered  an 
operative  procedure  superfluous,  as  it  could  have  had  no  in- 
fluence on  the  pulmonary  disease,  which  steadily  progressed  to 
an  unfavorable  issue.  The  only  symptom  attributable  to  the 
growth,  in  this  instance,  was  a  moderate  degree  of  hoarseness. 

Fig.  92  represents  the  laryngoscopic  appearance  of  a  fibroid 
polyp,  which  I  removed  with  the  forceps  of  Fauvel  from  be- 
neath the  left  vocal  cord  of  a  lady  of  Philadelphia.  A  de- 
tailed account  of  the  case  has  been  published  elsewhere.' 

Where  the  growths  are  large,  it  is  only  very  seldom  that  they 
can  be  removed  in  mass.  As  a  rule,  small  pieces  are  torn  off, 
from  time  to  time,  so  that  a  number  of  operations  are  necessary 
before  the  larynx  can  be  cleared. 

Figs.  93  and  94  will  represent  a  case  of  this  kind,  which  was 
referred  to  me  by  Prof.  Stille,  of  Philadelphia,  June  3, 1870.    On 


Pig.  93 


Fig.|94. 


Laryngeal  growths  removed  by  ] 
evulsion  and  caustics.  . 


Same  case  as  Fig.  93,  after  re- 
moval of  gi'owths. 


introducing  the  laryngoscopic  mirror,  I  saw  a  large  papillomatous 
growth,  the  size  of  a  filbert,  upon  the  left  side  of  the  larynx, 
and  a  small  growth  of  the  same  nature  upon  the  right  vocal 
cord.  Introducing  the  laryngeal  forceps  of  Cuzco,  I  removed 
quite  a  large  piece  of  the  main  growth  at  the  very  first  attempt, 
and  sent  it  to  Prof.  Stille  for  microscoj^ic  examination.  It  was 
handed  to  Prof.  Tyson,  microscopist  to  the  Philadelphia  Hos- 
pital, who  pronounced  it  a  simple  epithelial  formation. 

On  the  following  day  Dr.  Stille  examined  the  patient  with 
me,  confirming  my  diagnosis,  and  approving  of  the  treatment. 


1  Am.  Jour.  Med.  Sci.,  April  and  October,  1867. 


TEEATMENT    OF    GROWTHS   IIST    LAEYI^X.  435 

The  patient  visited  me  from  day  to  day  with  frequent  intervals, 
and  I  gradually  cleared  the  larynx  by  the  method  of  evulsion, 
until  finally,  at  the  end  of  three  weeks,  it  presented  the  appear- 
ance shown  in  Fig.  94.  During  the  course  of  treatment  it  was 
found  that  the  large  growth  was  multiple,  growing  from  the 
vocal  cord  as  well  as  from  the  ventricle  and  ventricular  band. 
The  amount  of  tissue  removed  was  much  greater  than  the  mass 
of  a  filbert. 

The  remnants  of  the  growth  were  cauterized  with  concentrated 
carbolic  acid ;  and  when  the  patient,  a  married  lady  about  twenty- 
six  years  of  age,  left  for  her  home  in  the  centre  of  the  State,  her 
voice,  which  was  completely  aphonic  at  the  time  I  first  saw  her, 
and  which  had  been  very  hoarse  for  about  a  year  and  a  half, 
was  in  excellent  condition.  She  was  recommended  to  continue 
for  some  time  daily  inhalations  of  a  weak  solution  of  carbolic 
acid.  A  few  months  later  I  received  a  letter  from  her  physi- 
cian, informing  me  that  her  voice  had  continued  to  improve  in 
strength  and  clearness,  and  that  it  was  at  that  time  in  all  re- 
spects satisfactory,  and  could  be  heard  at  a  considerable  distance 
down  the  road,  and  that,  at  the  time  of  writing,  there  was  no 
evidence  of  growths  having  been  in  the  larynx.  Within  a  few 
weeks  I  unexpectedly  received  a  grateful  letter  from  the 
patient's  husband,  informing  me  that  all  evidence  of  the  tumor 
(as  confirmed  by  a  laryngoscopic  examination  made  by  her  phy- 
sician) had  long  disappeared,  and  that,  save  a  slight  huskiness, 
her  voice  is  as  good  as  ever ;  and  that  she  had  not  used  her 
inhalations  for  over  a  year. 

Excision  with  knife  or  scissors  is  sometimes  practised  for  the 
removal  of  growths  from  the  larynx.  The  use  of  the  knife  is 
also  necessary,  occasionally,  to  detach  a  portion  of  a  growth  at 
its  base,  in  order  the  better  to  adapt  it  for  removal  with  the  for- 
ceps. Besides  this,  a  minute  growth  on  the  edge  of  one  of  the 
vocal  cords  which  cannot  be  seized  in  the  forceps,  may  sometimes 
be  detached  by  piercing  its  base  with  a  small  lance-shaped  knife, 
which,  as  it  is  pushed  onward,  severs  the  growth  from  the  cord. 
The  danger  of  dropping  the  tumor  in  the  trachea  has  caused 
some  objection  to  this  operation.  The  chances  are  greater 
that  it  would  be  coughed  out ;  but  if  not  coughed  out  at  once, 


436 


AFFECTIONS    OF    THE    LAETNX    AISTD    TEACHEA. 


it  would  doubtless  be  discharged  subsequently  in  the  expectora- 
tion. It  is  hardly  likely  that  a  nodule  the  size  of  a  large  pin 
would  be  inhaled  into  one  of  the  smaller  bronchi ;   and  if  this 


Fig.  96. 


Tobold's  concealed  knife  (Tobold). 


Tobold's  laricct-pointed 
probe  (after  Tobold). 


were  to  happen,  it  is  likely  that  the  irritation  it  would  produce 
would  lead  to  its  expectoration  iii  the  products  of  secretion. 

The  knife  is  also  required  for  the  division  of  membranous 
bands,  stretching  from  one  vocal  cord  to  the  other,  and  also  for 


TREAT3IENT    OF    GROWTHS    IIST    LARYNX. 


437 


the  division  of  the  commissure  which  often  unites  the  anterior  por- 
tion of  the  vocal  cords  after  removal  of  growths  from  them 
bj  external  incision;  the  operation  being  requisite  not  so  much 


Fig.  97. 


Fig.  98. 


Tobold's  knife,  with  double 
cutting  edge  Rafter  Tobold). 


Tobold's  knife,  with  single  cut- 
ting edge  (after  Tobold). 


for  relief  of  dyspnoea,  but  rather  to  improve  the  character  of 
the  voice,  which  is  shrill,  in  consequence  of  the  shortened  size  of 
the  vibrating  reeds,  thus  raising  its  pitch. 


438 


AFFECTIONS    OF   THE   LAKYNX   AND   TRACHEA. 


Again,  growths  within  the  ventricle  of  the  larynx  may  re- 
quire a  division  of  the  ventricular  band  by  the  knife,  in  order 
to  bring  them  within  reach  of  the  forceps. 


Fig.  99. 


Fig.  100. 


Tobold's  perpendicularly  cut- 
ting scissors  (after  Tobold). 


Tobold's  horizontally  cut- 
ting scissors. 


Scissors,  or  bladed  forceps,  have  been  sometimes  used  for 
the  removal  of  growths  of  unusual  hardness  and  favorably 
situated. 

An  idea  of  the  appropriate  instruments  for  all  these  pur- 
poses will  be  gained  from  the  accompanying  illustrations : — 


TEEATMEXT    OF    GROWTHS    IX    LAEYIS'X. 


439 


The  use  of  cutting  instruments  entails  a  good  deal  more  lieni- 
orrliage  than  instruments  for  crushing  or  for  evulsion. 

For  the  same  purpose  small  guillotine  knives  of  A'arious  forms, 
acting  on  the  principle  of  the  simple  tonsillotome,  have  been  de- 

[Fig.  1C2. 


Fiff.  101. 


Gibb's  wire-Hiare  for  larynx 

(Gibb.)  Tobold's  wire-snare  for  larjTigea]  growths  (Tobold). 

-vised  by  Tiirck/Stoerk,  Lewin,  and  others  ;  but  their  use  has  not 
been  attended  with  a  great  amount  of  satisfaction. 

In  cases  of  small  growths  favorably  situated.  Dr.  Mackenzie 
prefers  the  use  of  rigid  loops  or  rings  of  wire  of  various  shapes, 


440  AFFECTIOiSrS    OF   THE    LAETNX   Aj^D    TRACHEA. 

and  presenting  at  various  angles  to  the  stock,  the  inner  edge  of 
the  ring  being  sharpened,  so  tliat  when  the  growth  is  encircled 
bj  the  ring  it  can  be  jerked  or  scraped  off. 

Another  class  of  cutting  instruments,  suitable  for  the  re- 
moval of  growths  with  narrow  pedicles,  consists  in  wire-snares, 
similar  to  those  used  bj  Wilde  and  others  for  the  removal  of 
aural  polyps. 

An  instrument  of  this  kind  was  first  employed  by  Dr.  Gibb 
for  the  removal  of  laryngeal  growths,  and  in  his  hands,  and  in 
the  hands  of  some  others,  has  been  used  with  considerable  success. 
The  great  difiiculty  in  its  employment  consists  in  ensnaring  the 
growth,  and  in  drawing  the  wire  evenly  round  its  base,  a  nicety 
of  manipulation  which  the  author  has  been  unable  to  acquire ; 
and  therefore  he  has  not  resorted  to  this  procedure  for  a  num- 
ber of  years.  In  one  case,  in  which  he  succeeded  in  encir 
cling  a  polyp  to  his  satisfaction,  the  wire  broke  on  drawing 
it  home,  and  he  had  some  difficulty  in  disengaging  it  fi'om  the 
growth,  being  compelled  to  remove  the  wire  from  the  in- 
strument for  that  purpose.  The  growth  in  question  was 
removed  subsequently  with  a  pair  of  curved  forceps.  These 
instruments  have  been  called  ecrasem's,  but  they  do  not  act  on 
the  principle  of  the  ecraseur,  which  is  a  crushing  instrument. 
They  cut  through  the  tumor  more  after  the  manner  of  'a  knife. 

Dr.  Mackenzie  speaks  ^  of  a  true  wheel  ecraseur,  which  he 
has  had  made  for  the  larynx,  of  his  illustration  of  which  he 
has  kindly  sent  me  an  electrotype.  He  states  that  from  the 
slowness  with  which  it  acts  it  can  only  be  used  when  tracheotomy 
has  been  previously  performed,  or  where  the  growth  is  external 
to  the  laryngeal  canal.  It  is  only  adapted  to  large  growths  ;  and 
the  inventor  has  succeeded  in  removing  two  by  its  means,  one 
of  the  size  of  a  cherry  from  the  under  surface  of  the  epiglottis, 
and  the  other  of  the  size  of  a  bantam's  egg,  from  the  posterior 
surface  of  the  cricoid  cartilage.  From  the  illustration,  Fig.  103, 
it  would  appear  that  he  uses  a  wire  and  not  a  chain. 

Tobold  has  constructed  a  real  ecraseur.  Fig.  104,  provided  \vith 
a  small  chain,  such  as  is  used  in  watches.     I  jiave  tried  to  em- 

'^On  Growths  in  the  Larynx,  p.  78. 


TREATMENT    OF    GROWTHS    IIST    LAEYNX. 


441 


ploy  this  instrument  once  or  twice,  but  failed  in  my  attempts  to 
use  it  with  any  success. 

The  galvano-cautery,  as  first  suggested  by  Prof.  Middeldorpf / 
of  Breslau,  has  been  employed  for  the  removal  or  destruction  of 
laryngeal  growths,  and  is  recommended  on  the  score  of  thorongh- 

Fig. 


103. 


Fig.  104. 


Guarded  wheel  ecraseur 
(ilackenzie). 


Tobold's  chain  ecraseur 
(after  Tobold). 


ness  of  action  and  the  slight  risk  of  hemorrhage.  Tlie  principle 
consists  in  cutting  through  the  tumor  by  means  of  a  loop  or  blade 
of  platinum  heated  to  a  white  heat  by  the  electric  current.  The 
loop  is  passed  around  the  growth,  and  drawn  tightly,  the  same  as 


^  Die  Galvanokaustik.     Breslau,  1854. 


442  AFFECTIO]S"S    OF    THE    LARYIfX   AXD    TEACHEA. 

for  removal  by  the  wire-snare  or  ecraseur,  and  then  the  current 
being  passed  through  it,  the  growth  is  cut  through  and  usually 
comes  away  attached  to  the  instrument.  The  blade  is  pressed 
through  the  growth. 

Fig.  105  represents  the  instrument  devised  for  the  pm-pose 
by  Prof.  Yoltolini,  of  Breslau ;  and  Fig.  106,  a  mere  cautery  or 
blade,  much  lighter  in  construction,  devised  by  myself. 

Fig.  105. 


Voltolini''s  laryngeal  galvano-cautery. 
Fig.  106.  j 


A  simple  form  of  galvano-cantery  for  the  larynx.  ] 

!■  Figs.  lOr,  108, 109, 110,  111,  112  represent  the  instruments  em- 
ployed by  Prof,  von  Bruiis  of  Tubingen  ;  for  the  illustrations  of 
which  I  am  indebted  to  Doctors  Beard  and  Rockwell,  of  Xew 
Tork.^ 

This  method  of  treatment  has  been  recommended  by  Yolto- 
lini,°  von  Bruns,'  and  others,  and  has  often  been  used  with  sue 


^  Medical  and  Surgical  Electricity.     New  York,  1871. 

^  Die  Anwendnng  der  Galvanokaustik  im  innem  des  Kehlkopf  es  und  Schlund- 
kopfes.     Wien,  1867. 

'"  Neue  Beobachtungen  von  Polypen  des  Kehlkopfes.  Tiibinj^en,  1868. 
Die  Galvano-Chirurgie.     Tubingen,  1870. 


TEEATMENT    OF    GEOWTHS    IN    LAEYNX. 


443 


cess  ;  but  on  account  of  the  inf  requency  with  which  one  meets 
with  cases  calling  for  this  treatment,  and  the  trouble  and  expense 
attendant   upon  keeping  a  suitable  voltaic  apparatus  in   good 


Fig.  108, 


D 


Fig.  iio. 


Fig.  109. 


Von  Bruns'  instruments  for  galvano-cautery  (Bruns). 

Fig.  107.  Handle  for  cauteries,  with  knob  and  spring  for  making  and  brealcing 
the  current. 

Fig.  108.  Handle,  with  cutting  wire,  loop  or  snare. 

Fig.  109.  Handle,  for  use  with  one  hand,  whUe  the  other  is  occupied  with 
the  laryngoBCopic  mirror. 

Fig.  110.  Cauteries  of  -various  shapes  l^one,  blade-like,  for  cutting. 

Fig.  111.  Lar3'ngeal  cautery. 

Fig.  112.  Laryngeal  cutting  wire,  loop,  or  snare. 


Fig.  112. 


444  AFFECTIONS    OF    THE    LARYNX   AND    TEACHEA. 

order,  and  the  difficulty  of  obtaining  skilled  assistance  at  the 
desired  moment,  the  attendant  inconveniences  will  render  the 
employment  of  the  galvano -cautery  to  be  viewed  as  a  surgical  ac- 
complishment rather  than  a  surgical  practice,  at  least  as  far  as 
growths  in  the  larynx  are  concerned,  until  such  time  as  the 
technics  for  its  manipulation  shall  become  much  simplified.  I 
have  resorted  to  it  once  or  twice  where  I  feared  hemon-hage, 
and  with  less  pain  to  the  patient  than  the  use  of  the  ordinaiy 
caustic  remedies.  Dr.  Da  Costa,  who  witnessed  one  of  these 
manipulations,  was  much  struck  with  the  small  amount  of  incon- 
venience it  produced.  Dr.  Mackenzie,  whose  experience  in  the 
treatment  of  laryngeal  growths  is  perhaps  unequalled  anywhere 
in  the  world,  does  not  recommend  the  galvano-caustic  treatment. 
He  found  it  give  a  great  deal  of  pain  in  one  instance,  and  pro- 
duce acute  oedema  in  two  others.  He  recognizes  no  special  ad- 
vantages in  the  treatment,  and  considers  the  other  modes  of 
operating  amply  sufficient. 

Fig.  113  is  introduced  for  the  purpose  of  showing  a  little 
Fig.  113.  growth  on  a  depressed  epiglottis,  which 

induced  cough  by  touching  the  pharynx 
in  deglutition.  As  I  was  making  some 
experiments  with  the  galvano-cautery  at 
the  time  this  case  came  under  treatment, 
the  method  was  employed  to  destroy  the 
tumor,  which  it  did  readily  and  with 
Pimple  on^^nSto^  removed  ^'Gry  little  paiu  to  the  patient.  But  it 
by  galvano-cautery.  might  have  bccu  Snipped  off  with  hori- 

zontal scissors  just  as  readily. 

In  cases  of  phthisis,  some  caution  is  necessary  in  interfering 
unnecessarily  with  a  growth  in  the  larynx,  inasmuch  as  the  re- 
sulting nicer  may  not  cicatrize  kindly ;  and  this  may  precipitate 
all  the  unpleasant  accompaniments  described  in  the  account 
given  of  the  chronic  laryngitis  of  phthisis. 

Under  certain  circumstances  it  becomes  necessary  to  divide 
the  laijnx  externally  for  the  removal  of  morbid  growths  within 
it.  This  necessity  arises  sometimes  on  account  of  the  position  of 
tliG  growth,  rendering  it  inaccessible  to  intra-laryngeal  procedure ; 


TREATMENT    OF    GROWTHS    IN    LARTjSTX. 


445 


sometimes  from  the  great  size  of  the  growth  and  the  danger  of 
hemorrhage  in  its  extraction ;  and  almost  always  when  the  growth 
is  malignant  in  character.  When  a  growth  is  malignant,  no 
matter  where  it  may  be  sitnated,  if  at  all  submitted  to  operative 
procedure,  it  is  essential  that  every  portion  of  it  be  removed — 
in  the  language  of  Prof.  Gross,  that  "  the  very  atmosphere  of 
the  morbid  mass  be  removed,"  and  this  cannot  be  done  without 
dissection  ;  and  dissection  cannot  be  practised  with  instruments 
adapted  to  laryngoscopic  surgery. 

The  division  of  the  larynx  may  be  performed  at  once,  or  not 
until  after  the  previous  performance  of  tracheotomy.'  Where 
the  growth  is  small,  or  even  if  it  were  large,  and  the  probabili- 
ties were  that  after  splitting  the  larynx,  the  operation  for  re- 
moval of  the  growth  would  be  a  simple  one,  such  as  strangula- 
ting or  cutting  out  a  tumor  without  ramifying  adhesions,  so  that 
a  comparatively  slight  amount  of  injury  would  be  inflicted  upon 
the  intra-laryngeal  structures,  I  would  be  inclined  to  open  the 
larynx  at  once,  without  the  previous  performance  of  tracheotomy. 
Where,  on  the  other  hand,  a  great  amount  of  injury  of  this  kind 
is  anticipated,  injury  which  would  lead  to  a  good  deal  of  inflam- 
mation. I  would  be  inclined  to  perform  tracheotomy  in  advance, 
in  order  to  facilitate  respiration  and  keep  the  injured  parts  at 
rest. 

Fig.  114  represents  the  laryngoscopic 
appearance  of  a  fibrous  growth,  for  the 
removal  of  which  I  divided  the  larynx 
without  having  performed  tracheotomy. 
The  patient  was  a  man  aged  26  years,  and  a 
subject  of  phthisis.  Dyspnoea,  on  account 
of  which  the  operation  was  performed, 
was  relieved ;  but  although  the  growth 
was  favorably  situated,  and  the  vocal 
cords  were   uninjured   in  the  .operation,   the  aphonia  existing 


Pig.  114. 


Fibrous  tumor  on  risht  vocal 
cord  removed  after  thyroto- 
my,  without  tracheotomy. 


^  Dr.  Ephraim  Cutter,  of  Boston,  was,  I  believe, ^.the  first  surgeon  to  perform 
this  operation  without  recourse  to  tracheotomy.  He  has  recently  published  an 
account  of  nine  cases  of  the  kind,  in  a  pamphlet  entitled,  "  Thyrotomy, 
for  the  Removal  of  Laryngeal  Growths,  Modified."     Boston,  1871. 


446 


AFFECTIOXS    OF    THE    LAETXX   AND    TEACHEA. 


prior  to  the  operation   persisted  after  it.     A  detailed  account 
of  this  case  has  been  given  elsewhere.^ 

Figs.  115,  116,  117  represent  three  views  of  the  larvnx  of  a 
young  gentleman,  from  whose  left  vocal  cord  and  ventricle  I 
removed  a  large  epithelioma,  as  well  as  two  much  smaller 
growths  from  the  right  vocal  cord,  after  the  previous  perfonn- 
ance  of  tracheotomy.  Fig.  115  represents  the  appearance  of  the 
growth  at  the  time  of  the  operation  ;  Fig.  116,  the  appearance 
of  the  larynx  a  few  months  after  the  0]3eration ;  and  Fig.  117, 
the  appearance  of  the  parts  nearly  four  years  after  the  operation. 
In  tlie  last  two  figures  the  line  of  the  tracheal  incision  is  dis- 
tinctly seen.  An  important  feature  in  connection  with  this  case, 
which  is  reported  in  detail  elsewhere,^  consists  in  the  fact  that 
there  was  a  reproduction  of  tissue  in  the  left  vocal  cord,  the 

Fig.  115.  Kg.  116.  Fig.  117. 


Laryngeal  growths,  for  the  removal 
of  which  thjTotomy  was  per- 
formed after  tracheotomy. 


Appearance  of  the  parts  some 
months  after  the  operation. 


Appearance  of  the  parts  some 
years  after  the  operation. 


anterior  portion  of  which  had  been  purposely  sacrificed  in  the 
removal  of  the  growth,  and  from  which  an  expansion  took  place 
to  the  other  cord  anteriorly,  as  well  depicted  in  the  drawings. 
This  case  was  eminently  successful  as  to  the  restoration  of  the 
voice,  the  patient  declaring  th^t,  although  a  little  rough,  his 
voice  is  as  good  as  it  ever  was.  This  shows  us  that  the  vocal 
cords,  or  a  substitute  for  them,  can  be  reproduced,  and  seems 
to  confirm  the  view  that  they  are  mere  duj)licatures  of  elastic 
membrane,  and  not  special  structures. 

I  have  seen  some  of  these  operations  accomplished  without 
any  difliculty,  and  accompanied  by  very  little  hemorrhage. 
Others  have  been  attended  with  serious  difliculties. 


^  The  Medical  Record^  vol.  iv. , 
^  Ibid.,  vol.  iv.,  p.  244. 


p.  218. 


I 


TEEATMENT    OF    GEOWTIIS   IN    LAET]S-X.  447 

Tlie  first  operation  of  thyrotomy  for  remoTal  of  laryngeal 
growth  was  performed  by  Brauers  in  1833,  and  was  followed 
by  Ehrmann  in  1843,  and  by  Buck  in  1851  and  1861,'  since 
which  time  it  has  been  frequently  repeated. 

In  performing  the  operation  of  external  section  of  the  thyroid 
cartilage,  for  the  removal  of  laryngeal  growths,  the  patient 
is  j)l3,ced  in  the  nsnal  position  for  laryngotomy  or  trache- 
otomy, or  may  be  seated  upon  a  chair  thrown  back,  and 
steadily  supported.  The  anterior  portion  of  the  larynx 
being  freely  exposed  by  section  of  the  skin  and  subcutaneous 
connective  tissue,  a  vertical  opening  is  made  into  the  crico- 
thyroid ligament  by  a  sharp-pointed  knife,  the  blade  presenting 
upwards,  and  this  may  then  be  carried  upwards,  separating  the 
anterior  wall  of  the  larynx  into  halves,  care  being  taken  to  keep 
in  the  middle  line,  to  avoid  wounding  the  vocal  cords.  If  pre- 
ferred, the  section  of  the  cartilage  may  be  performed  by  means 
of  a  probe-pointed  knife.  The  knife  employed  should  be  very 
strong ;  and  a  stout  paij-  of  angular  scissors  should  be  at  hand,  to 
be  used  for  dividing  the  cartilage,  should  the  latter  be  ossified 
or  offer  much  resistance  to  the  knife.  If  the  growth  present  in 
the  line  of  incision,  it  will  be  very  apt  to  be  w'ounded  and 
give  rise  to  hemorrhage.  The  severed  halves  of  the  thyroid 
cartilage  are  to  be  held  apart  by  strong  blunt  hooks,  for  which 
purpose  Dr.  Cutler,  of  Boston,  has  devised  ^  a  pair  of  double 
pronged  hooks,  looking  like  a  pair  of  old-fashioned  table-forks, 
with  the  terminal  ends  turned  downwards ;  the  intention  being 
to  place  one  prong  above  the  vocal  cord  and  one  below  it,  in 
using  the  instrument.  The  morbid  growth  is  then  removed  by 
forceps,  knife,  scissors,  ecraseur,  or  galvano-cautery,  as  may  be 
deemed  most  expedient ;  and  after  the  operation,  the  raw  places 
should  be  cauterized  with  nitrate  of  silver,  or  with  a  compara- 
tively strong  solution  of  acid  nitrate  of  mercury.  The  wound 
is  allowed  to  come  together  naturally,  and  the  parts  are  held  in 
position  by  adhesive  strij^s  externally.  There  is  no  necessity  to 
place  a  suture  in  the  cartilage,  or  even  in  the  skin.  Some 
disturbance  of  the  parts  must  ensue  during  the  paroxysms  of 

1  Mackenzie.     Growtlis  in  the  Larynx,  p.  89. 
*  Am.  Jour.  Med.  Sci.,  January,  1867. 


448  AFFECTIOlSrS    OF    THE    LATiYlSTX   AND    TRACHEA. 

cougli  that  usually  continue  for  a  few  days  after  an  operation 
of  this  kind.  A  simple  dressing  is  all  that  is  required.  When 
the  wound  is  dressed,  a  full  opiate  should  be  administered. 
Liquid  nourishment  can  usually  be  taken  from  the  very  first, 
though  swallowing  is  sometimes  difficult  for  a  few  days. 

During  the  operation  it  is  very  essential  that  the  blood  should 
be  promptly  sopped  up  by  small  bits  of  sponges,  securely  at- 
tached to  forceps,  or  what  I  prefer,  to  rods  of  whalebone  ;  and 
several  of  these  should  be  at  hand.  In  one  of  my  operations, 
an  assistant,  excited  by  the  spattering  of  the  blood  accompany- 
ing the  spasmodic  heaving  of  the  respiration,  induced  in  these 
operations  by  the  presence  of  blood  and  the  direct  access  of 
cool  air,  dropped  a  piece  of  sponge  from  the  forceps,  and  it  was 
absolutely  on  its  way  down  the  trachea  in  the  ins23iratory  cur- 
rent, when  I  seized  it  with  the  forceps  and  extracted  it.  Tiie 
possibility  of  such  an  untoward  accident  may  be  avoided  by 
securing  the  sponge  firmly  and  permanently  to  its  holder.  Re- 
covery from  these  operations  is  usually  prompt,  unless  the  general 
state  of  the  constitution  has  become  much  impaired  beforehand. 

The  mere  opening  of  the  larynx  is  a  matter  of  little  difficulty, 
but  the  extirpation  of  a  tumor  with  extensive  attachments  is  a 
matter  of  a  good  deal  of  labor  and  responsibility ;  on  the  one 
hand  on  account  of  the  spasmodic  heaving  of  the  parts  at  every 
touch  of  the  knife  or  other  instrument,  and  on  the  other  hand 
on  account  of  the  passage  of  blood  into  the  trachea. 

It  is  not  a  settled  question,  whether  the  use  of  ansesthetics 
should  be  employed  for  the  j^erformance  of  these  operations. 
All  in  which  the  author  was  interested  as  principal  or  assistant 
were  performed  under  the  influence  of  anaesthesia,  the  effect  of 
which  as  a  rule  was  very  satisfactory.  In  one  case,  liowever,  in 
which  I  was  assisting  Dr.  Elsberg  of  Xew  York  at  the  time,  the 
patient,  an  elderly  man,  nearly  died  from  the  chloroform,  and 
after  he  was  revived  the  operation  had  to  be  finished  without 
further  resort  to  anaesthesia.  In  another  instance  which  I  have 
reported  in  detail,'  death  actually  occurred  from  the  administra-^ 
tion  of  the  anaesthetic.  It  must  not  be  forgotten,  in  this  con- 
nection, that  if  the  integrity  of  the  glottis  is  already  compro- 
'  The  Medical  Hecord,  vol.  iv. ,  p.  365. 


TREATMENT    OF    GROWTHS    IN    LARYNX.  449 

mised  by  the  presence  of  a  large  neoplasm,  there  is  danger  of 
death  by  suffocation  during  the  administration  of  an  anaesthetic, 
despite  the  usual  relaxing  influence  of  such  an  agent.  It  would 
be  well,  therefore,  in  cases  where  there  is  any  doubt  upon  the  pro- 
priety of  employing  anaesthesia,  to  make  the  initial  incision 
beforehand,  inasmuch  as  statistics  show  us  that  death  is  much 
less  likely  to  occur  when  an  anaesthetic  is  administered  for  relief 
from  pain,  than  when  it  is  given  for  the  purpose  of  preventing 
pain. 

After  removal  of  a  growth  by  this  means,  the  parts  from 
which  it  has  been  removed  should  be  thoroughly  cauterized  with 
lunar  caustic  or  the  acid  nitrate  of  mercury,  with  a  view  of  re- 
pressing repullulation. 

In  all  cases  of  intense  dyspnoea  threatening  suffocation,  con- 
nected with  a  grow^th  in  the  larnyx,  laryngotomy  or  tracheotomy 
should  be  performed  as  an  initial  measure,  even  when  it  is  in- 
tended to  extract  the  growth  through  the  mouth.  The  danger 
of  provoking  spasm  by  tentative  efforts  is  not  to  be  underrated. 
In  addition  to  this,  the  laryngeal  or  tracheal  wound  can  be 
taken  advantage  of  for  gaining  access  to  the  neoplasm,  as  has 
been  practised  by  Mackenzie,  von  Bruns,  and  others ;  the  mani- 
pulation being  guided  by  the  laryngoscope. 

If  tracheotomy  have  been  performed  previous  to  the  removal 
of  malignant  growths,  or  benign  growths  with  a  disposition  to 
recurrence,  it  would  be  "well,  unless  strongly  contra-indicated, 
to  retain  the  use  of  the  canula  for  a  greater  or  shorter  time. 
This  would  afford  two  avenues  to  the  new  growth,  and  insure 
freedom  of  respiration  should  the  new  growth  enlarge  rapidly. 
Patients  from  a  distance  should  be  taught  the  art  of  auto- 
laryngoscopy,  so  that  they  can  examine  their  own  laryngeal  struc- 
tures from  time  to  time,  and  detect  any  recurrence  of  growth 
in  its  early  stages. 

Scirrhus  and  encephaloid  growths  in  their  advanced  state 
are,  as  a  rule,  not  suitable  for  radical  operation,  inasmuch  as  so 
much  of  the  surrounding  structures  are  usually  involved  as  to 
render  complete  removal  impossible  without  the  sacrifice  of  im- 
portant functions.  True,  it  has  been  proposed  to  remove  the 
entire  larynx,  and  the  operation  has  been  performed  by  Czerny 
29 


450        AFFECTIONS    OF    THE    LARYNX   AND    TEACHEA. 

successfully  on  the  lower  animals.  In  a  case  of  scirrlius  of  the 
larynx,  which  I  examined  a  year  or  two  ago  with  Prof.  Post  of 
New  York,  that  gentleman  proposed  removal  of  the  mass,  in- 
cluding as  much  of  the  larynx  as  would  be  necessary  for  that 
purpose ;  and  he  would,  in  all  probability,  have  performed  the 
operation  had  the  patient  not  committed  suicide.  We  can  con- 
ceive of  the  possibility  of  a  man's  living  without  a  larynx,  and 
that  there  are  many  individuals  who  would  prefer  living  as 
mutes,  and  feeding  by  the  stomach  tube,  to  not  living  or  feed- 
ing at  all.  Nevertheless,  the  operation  is  hardly  to  be  considered 
justifiable  in  cases  of  malignant  growth. 

Another  method  of  external  operation  for  the  removal  of 
laryngeal  growths  remains  to  be  spoken  of.  This  is  the  opera- 
tion of  supra-thyroid  laryngotomy,  or  sub-hyoidean  pharyngo- 
tomy,  as  it  is  called,  a  method  of  gaining  access  to  the  pharynx 
and  to  the  larynx  by  drawing  the  epiglottis  through  a  wound 
made  in  the  external  tissues.  This  operation  was  proposed  by 
Malgaigne  ^  and  by  Yidal  de  Cassis,  and  was  performed  for  the 
first  time,  on  the  person  of  an  American  gentleman,  by  Dr. 
Prat,^  a  French  naval  surgeon,  stationed  at  the  time  at  Papiete, 
the  capital  of  Otaheite.  A  fibroid  tumor  existed  on  the  epi- 
glottis, w^hich  could  be  felt  with  the  finger,  but  it  could  not  be 
extracted  through  the  mouth.  The  patient,  who  was  the  subject 
of  advanced  pulmonary  phthisis,  suffered  also  from  extreme 
dysphagia,  which  finally  increased  to  veritable  aphagia.  There 
was  also  difiniculty  of  breathing.  The  patient,  who  could  neither 
eat  nor  drink,  insisted  on  being  relieved,  and  Dr.  Prat  operated 
in  accordance  with  the  directions  of  Malgaigne.  The  transverse 
incision  2-3  millimeters  in  length,  through  the  thyro-hyoid  mem- 
brane, brought  him  down  to  the  epiglottis,  upon  the  left  side  of 
the  laryngeal  face  of  which  the  tumor  was  found.  It  was  seized 
with  forceps,  and  excised  with  scissors.  No  vessels  required 
ligature.     The  edges  of  the  wound  were  united  by  suture,  and  a 

^  Manuel  de  Med.  Operatoire.  Paris,  1835. 

2  (Gazette  des  Hopitaux,  1859,  No.  103)  Elsberg's  Prize  Essay  on  the  Treat- 
ment of  Morbid  Growths  within  the  Larynx.  Phila.  1866,  p.  15.  Mackenzie ; 
On  Growths  in  the  Larynx,  p.  98. 


TREATMENT    OF    GROWTHS    IN    LARYNX.  451 

dressing  was  applied  rather  tightly.  The  wound  healed  rapidly, 
and  the  troubles  of  respiration  and  deglutition  subsided.  The 
patient  died  shortly  afterwards  from  phthisis,  and  at  the  autopsy 
no  trace  of  the  growth  was  to  be  found. 

In  1863,  Dr.  FoUin  ^  performed  a  similar  operation  with 
complete  success.  The  patient  was  a  young  man,  aged  21 
years,  whose  respiration  was  normal  when  in  the  horizontal 
position,  but  who  could  not  breathe  when  standing  upright. 
His  symptoms  were  due  to  the  presence  of  several  fibro-cellular 
or  mj^xomatons  growths,  which  had  formed  rapidly,  and  were 
thought  to  be  situated  on  the  posterior  wall  of  the  larynx. 
The  neoplasms  were  extirpated,  and  the  patient  was  entirely 
cured. 

Prof,  Langenbeck  also  has  operated  ^  in  this  manner.  His  first 
operation  was  July  4, 1862,  performed  upon  the  person  of  a  man, 
forty-seven  years  of  age,  from  whom  a  pharyngeal  tumor  about 
an  inch  in  circumference  had  been  removed  by  Prof.  Middel- 
dorpf  in  1859,  by  means  of  the  galvano-cautery.  The  tumor 
had  grown  again  to  very  large  dimensions,  and  threatened  death 
by  suffocation.  The  operation  was  a  difficult  one,  requiring  the 
use  of  some  twenty-five  ligatures  to  control  the  hemorrhage. 
The  patient  died  on  the  second  day  after  the  operation. 

Prof.  Langenbeck  operated  a  second  time,  and  successfully, 
in  August,  1 869,  upon  a  female  aged  fifty  years.  The  tumor 
arose  from  the  left  aryteno-epiglottic  fold,  stretched  with  a 
broad  base  to  the  left  side  of  the  pharynx,  and  was  so  firmly 
attached  to  the  left  arytenoid  cartilage,  that  the  cartilage  was 
brought  through  the  external  wound  along  with  the  growth, 
which  latter  was  then  carefully  separated  from  it.  The  tumor, 
when  removed,  was  of  the  size  of  a  large  pigeon's  egg,  irregular 
in  outline,  and  not  unlike  an  hypertrophied  tonsil  in  general 
appearance.  Microscopically  examined,  it  was  determined  to  be 
a  fibro-myxoma. 


^  Archives  Ginerales  de  if^fd,  February.  1807.  Mackenzie;  On  G-rowths, 
etc.,  p.  99. 

^  Allgemeine  Medicinische  Central- Zeitung,  1870,  Nos.  8,  9,  and  10,  pp.  93, 
103,  and  115. 


452      AFrECTiojS"s  of  the  laeynx  a]S"d  trachea. 

In  1863  Dr.  Debron  ^  performed  this  operation  for  tlie  re- 
moval of  a  tumor  which,  during  the  operation,  proved  to  be 
situated  in  the  ventricle  of  the  larynx.  The  thyroid  cartilage 
was  then  divided,  when  it  was  found  that  the  tumor  extended 
from  the  right  aryteno-epiglottic  fold  to  the  distance  of  2-3 
millimetres  below  the  vocal  cords.  It  was  removed  wdth  the 
ecraseur.  Tracheotomy  was  then  performed  and  a  canule  in- 
serted. The  patient  died  on  the  seventh  day  from  the  resulting 
bronchitis,  which  Debron  attributed  to  the  unnecessary  tracheo- 
tomy w^hich  he  had  performed. 

TUMOES    OF    THE    TRACHEA. 

Tumors  occur  in  the  trachea  also,  and  are  recognized  in 
the  laryngoscope.  Their  removal  usually  necessitates  laying 
the  tube  open  from  the  outside.  Occasionally,  however,  a 
tumor  may  be  removed  from  the  trachea  through  the  mouth, 
as  exemplified  in  the  following  case  of  extirpation  of  a  sarcoma 
from  the  trachea,  successfully  performed  by  Dr.  Schrotter,  a 
verbal  account  of  which  I  had  from  an  eye-witness.  Dr.  Aub, 
of  Cincinnati.  The  case  is  so  rare,  and  the  skilful  extirpation 
so  highly  creditable  to  the  operator,  that  no  apology  is  necessary 
for  presenting  an  extract  of  the  detailed  report  in  the  Wieri 
Medicinische  Jahrljuclier^  xv.  Baud,  1  Heft,  1868,  pp.  64-72. 

The  patient  was  a  journeyman  house-painter,  set.  thirty-four, 
who  had  been  under  treatment  for  a  long  time  for  chronic 
laryngeal  catarrh,  with  a  slight  cicatricial  contraction  of  the 
anterior  portion  of  the  left  vocal  cord.  Finally  the  laryngo- 
118.  scopic  examination  revealed  the  exist- 

ence of  a  tumor  (Fig.  118)  upon  the 
anterior  wall  of  the  trachea,  in  the 
region  of  the  fourth  tracheal  carti- 
lage, and  in  its  posterior  portion  it 
seemed  as  broad  as  the  dilated  glot- 

Dr.  Sch,.,^;;;^nas^^orof  the     tis.     It  WaS  of  a  pale  red   color,  cover- 
trachea  (Schrotter).  ed    here    and    there    with    yellowish 
mucus.     The  tumor  was  observed  to  move  with  forced  respi- 

•  Allg.  Med.  Cent.-Zeit.,  No.  9,  p.  105. 


TUMORS    OF    THE    TRACHEA.  453 

ration,  showing  that  it  had  a  pedicular  attachment  to  the 
230sterior  wall  of  the  trachea. 

Local  anaesthesia  was  produced  by  the  pencilling  first  with 
chloroform,  and  then  subsequently,  at  intervals  of  about  an 
hour,  with  a  solution  of  the  acetate  of  morphia — 10  grains  to  the 
drachm  of  water. ^  Portions  of  the  tumor  were  removed  by  the 
forceps  on  several  occasions,  and  finally  the  portion  remaining 
was  injected  with  a  solution  of  the  sesquichloride  of  iron,  two 
parts  to  one  of  water,  which  produced  cauterization  and  shrink- 
ing of  the  tumor,  to  a  mere  immovable  stump. 

It  would  have  been  a  better  and  safer  practice  to  have 
opened  the  trachea  externally,  and  have  removed  the  entire 
tumor  at  once,  cauterizing  the  points  of  attachment  to  pre- 
vent repullulation.  As  a  sample  of  pluck  and  patience  on  the 
part  of  the  operator,  and  endurance  on  the  part  of  the  patient, 
the  case  is  unique,  and  its  report  worth  perusal  by  those  inter- 
ested. 

A  case  of  polyp  of  the  trachea  is  recorded  °  by  Dr.  Fifield. 
The  patient,  a  female,  was  subject  to  attacks  of  dyspnosa, 
and  for  four  days  before  death  sat  Avith  her  forehead  on  the 
back  of  a  chair.  The  left  bronchus  was  perfectly  covered  by 
a  firm  rosy  polyp,  the  size  of  a  small  grape ;  the  ]3edicle  was 
attached  to  the  trachea  at  the  mouth  of  the  bronchus,  where  it 
had  acted  as  a  ball-valve,  permitting  expiration,  but  preventing 
inspiration.  The  case  was  unconnected  with  any  disease  of  the 
lungs. 

Dr.  Gibb  mentions  °  a  case  of  cystic  tumor  (cyst  or  abscess  ?^ 
on  the  anterior  wall  of  the  trachea,  which  burst  spontaneousl}'. 

Prof.   Ttirck''   has   observed   several  cases  of  tumor  of  the 

'  This  method  of  inducing  tolerance  of  the  parts  preparatory  to  operating 
■wdthin  the  larynx  is  much  used  in.  Germany,  but  I  do  not  think  it  is  in  favor 
elsewhere.  Dangerous  narcotism  is  sometimes  produced,  and  this  has  in  some 
instances  proved  fatal.  Prof.  Pancoast  informed  me  that  a  result  of  this  kind 
occurred  druing  his  recent  visit  to  Vienna,  and  I  have  been  told  of  other  in- 
stances by  reliable  gentlemen  engaged  in  studying  the  art  of  laryngoscopy 
abroad  at  the  time. 

=  {Boston  Med.  and  Surg.  Jour.,  Nov.  14,  18G1.)     Gibb,  op.  dt.,  p.  392. 

5  Op.  cit.,  p.  393. 

*  Klinik  der  Krankheiten  des  Kehlkopfes  und  der  Luftrohre.  Wien,  1866, 
p.  502,  et  seq. 


454        AFFECTIONS    OF    THE    LARYlfX   AND    TEACIIEA. 

trachea,  some  of  which  he  discovered  on  the  laryngscopic  in- 
spection ;  and  one  of  these  was  associated  with  growths  in  the 
upper  portion  of  the  left  bronchus. 

Most  of  the  cases  of  so-called  tumors  of  the  trachea,  however, 
are  involutions  of  the  tube  caused  by  the  compression  of  tumors 
external  to  the  windpipe  ;  or  extension  inwards  of  tumors  from 
the  CBSophagus,  the  latter  class  of  affections  being  usually  ma- 
lignant. The  description  of  a  marked  case  of  this  kind  is  illus- 
trated in  the  work  of  Dr.  Gibb,'  in  which  the  calibre  of  the 
tube  was  almost  entirely  filled  by  an  oval  tumor  an  inch  and  a 
quarter  in  length,  growing  from  the  posterior  wall  and  blended 
with  CBSophageal  disease. 

No  special  symptoms  of  tracheal  tumor  would  be  recognized, 
as  a  rule,  until  the  size  of  the  growth  was  such  as  to  produce 
stridor,  or  impede  respiration.  Early  in  its  growth,  its  existence 
might  possibly  be  recognized  or  suspected  by  diy,  sonorous  rales 
otherwise  unaccounted  for.  Tumors  in  connection  with  the 
oesophagus  would  be  accompanied  with  symptoms  of  dysphagia 
or  stricture,  in  addition  to  whatever  special  tracheal  symptoms 
might  be  present. 

FOEEIGN    BODIES    IN    THE   LAEYNX    AND    TEACIIEA. 

Foreign  bodies  frequently  gain  access  into  the  air-passages, 
and  when  not  promptly  expelled  by  coughing,  usually  become 
impacted  in  some  portion  of  the  larynx  or  trachea,  though  they 
occasionally  lodge  in  the  bronchi.  These  foreign  bodies  may 
gain  access  from  the  outside,  as  in  the  well-known  case  of  La 
Martiniere,  who  detected  a  small  wound  in  the  neck  of  a  boy 
who  had  been  suddenly  seized  with  a  paroxysm  of  suffocation 
while  playing  with  a  whip.  The  wound  was  cut  down  upon, 
and  a  pin  extracted  from  it.  The  pin  had  been  attached  to  the 
whip-cord,  and  had  penetrated  into  the  tracliea. 

A  purulent  bronchial  gland  has  been  known  to  become  de- 
tached, and  thus  produce  sudden  death  by  suifocation.  Matters 
vomited  from  the  stomach  during  a  state  of  insensibility  have 
been  known  to  inundate  the  air-passages,  and  thus  produce 
death.     An  accident  of  this  kind  sometimes  occurs  in  the  new- 

1  Op.  cit.,  p.  391. 


FOEEIGN    BODIES    IN    THE    LARYTsTX   AND    TEACHEA.    455 

born  babe,  the  matters  usually  consisting  of  mucus  and  meconium. 
Parasitic  worms  sometimes  tind  their  way  into  the  air-passage 
from  the  alimentary  canal ;  and  insects  and  other  animals  from 
the  nose. 

The  most  frequent  cause  of  the  entrance  of  foreign  bodies 
into  the  air-passages  is  due  to  sudden  inspiration  while  the 
body  is  in  the  mouth.  Hence,  many  accidents  of  this  kind 
occur  in  children  who  are  very  apt  to  put  things  into  their 
mouths  while  at  play. 

All  the  works  on  surgery  contain  reliable  articles  on  the  sub- 
ject of  foreign  bodies  in  the  air-passages,  and  it  is  therefore 
unnecessary,  in  the  present  volume,  to  do  more  than  give  a 
general  description  of  the  nature  of  the  accident,  the  symp- 
toms it  gives  rise  to,  and  the  treatment  indicated.  For  this 
purpose  the  author  has  seen  fit  to  draw  largely  upon  the 
classical  w^ork  of  Prof.  Gross,^  which  contains  all  the  essen- 
tial information  that  can  be  gained  on  the  subject,  with  the 
single  exception  that  these  bodies,  when  lodged  in  the  larynx, 
or  in  certain  portions  of  the  trachea,  can  sometimes  be  seen 
in  the  laryngoscopic  mirror — an  instrument  introduced  into  the 
practice  of  medicine  and  surgery  subsequently  to  the  publication 
of  Dr.  Gross's  volume.  When  they  can  be  so  seen,  and  an  ex- 
amination of  this  kind  should  not  be  neglected  when  time  and 
opportunity  permit,  valuable  information  is  obtained  as  to  the 
position  of  the  foreign  body,  and  the  selection  of  the  proper 
operation  for  its  extraction.  In  certain  favorable  cases,  the 
foreign  body,  when  situated  in  the  upper  portion  of  the  larynx, 
can  be  seized  with  a  pair  of  laryngeal  forceps  under  guidance 
of  the  laryngoscopic  mirror,  and  be  safely  extracted  through  the 
mouth.  When  the  foreign  body  is  situated  beneath  the  glottis, 
such  an  operation  is  not  advisable,  on  account  of  the  danger  of 
producing  suffocation  by  spasm  of  the  glottis,  or  by  impaction 
of  the  foreign  body  between  the  lips  of  the  glottis  in  the  effort 
at  extraction.  Only  when  the  body  is  small  or  slender,  and 
favorably  situated  for  seizing  and  withdrawing  it,  should  this 
operation  be  attempted. 

'  A  Practical  Treatise  on  Foreign  Bodies  in  tlie  Air- Passages.     Phila.,  1854. 


456  AFFECTIOlSrS    OF    THE    LAEYXX    AjSTD    TEACHEA. 

An  instructive  case  of  this  nature  occurred  recently  in  my  own 
practice,  in  the  case  of  a  lady  sent  to  me  from  a  neighboring 
city.  The  foreign  body,  a  piece  of  beef  bone,  had  been  inhaled 
into  the  larynx  while  eating  soup,  two  years  and  a  half  before. 
On  examination,  I  saw  the  bone  below  the  vocal  cords,  impacted 
between  the  anterior  and  posterior  walls  of  the  cricoid  cartilage, 
which  had  undergone  caries  at  these  points,  I  made  an  attempt 
to  seize  the  body  with  a  pair  of  laryngeal  forceps,  and  readily 
succeeded,  but  a  good  deal  of  force  was  necessary  to  dislodge  it, 
and  the  instrument  was  withdrawn  without  the  foreign  body  with- 
in its  grasp,  A  moderate  amount  of  hemorrhage  followed,  ac- 
companied by  violent  paroxysms  of  spasm  of  the  glottis,  which 
continued  for  about  half  an  hour,  and  were  eventually  allayed 
by  the  inhalation  of  ether,  A  subsequent  laryngoscopic  ex- 
amination showed  that  the  foreign  body  had  been  detached 
from  its  connections  posteriorly,  and  that  it  was  hanging  by  its 
anterior  attachment.  It  had  caught  under  the  vocal  cords  in 
their  spasmodic  contraction  during  the  operation,  and  had  thus 
been  dragged  out  of  the  grasp  of  the  forceps,  I  declined  to 
interfere  further  through  the  mouth,  and  subsequently  per- 
formed tracheotomy,  with  the  assistance  of  Drs.  Packard  and 
Sinkler.  The  bone,  which  was  distinctly  seen  just  before  the 
operation,  could  not  be  found  after  it,  and  it  was  concluded 
that  it  had  become  detached,  coughed  up,  and  swallowed  during 
the  spasms  of  coughing  with  which  the  operation  was  attended  ; 
and  the  case  has  done  well  ever  since.  The  ulceration  of  the 
cricoid  cartilages  healed  kindly,  their  progress  being  watched 
with  the  laryngoscope.  A  day  or  two  after  the  operation,  a 
small  piece  of  bone  was  found  plastered  by  a  clot  of  blood  to 
the  wall  in  front  of  the  position  occupied  by  the  operating  table, 
but  it  represented  only  a  small  portion  of  the  bone  seen  with 
the  laryngoscope. 

A  small  fish-bone,  and  several  pins,  which  had  been  inhaled 
into  the  larynx,  I  have  extracted,  without  difficulty,  under 
guidance  of  the  laryngoscope  ;  but  they  were  favorably  situated 
above  the  glottis.  Most  of  the  foreign  bodies  which  gain 
entrance  into  the  air-passages  are  of  hard  consistence,  and  not 
likely  to  undergo  alteration  of  size.     Vegetable  and  animal 


FOREIGN    BODIES    IN    THE    LARYNX    AND    TRACHEA.    457 

matters,  on  the  other  hand,  are  liable  to  become  increased  in 
size  from  imbibition  of  moisture,  and  therefore  add  gravity  to 
the  prognosis. 

The  foreign  body  may  lodge  in  different  portions  of  the 
larynx  or  trachea,  or  may  remain  loose  in  the  windpipe,  and 
move  np  and  down  it  with  the  efforts  of  respiration.  When  a 
foreign  body  is  not  arrested  in  the  larynx  or  trachea,  it  usually 
falls  into  one  of  the  bronchial  tubes,  more  frequently  into  the 
right  tube.  The  cause  of  this  peculiarity  is  shown  by  Prof.  Gross 
to  depend  upon  the  anatomical  arrangement  of  the  septum  at 
the  root  of  the  trachea,  where  that  tube  divides  into  tlie  pri- 
mar}^  bronchi.  This  bronchial  septum  is  to  the  left  of  the 
middle  line,  and  thus  a  foreign  body  striking  it  is  apt  to  be  de- 
flected to  the  right,  its  passage  in  this  direction  being  favored 
by  the  greater  calibre  of  the  right  bronchus.  Sometimes  a 
foreign  body  falls  into  each  bronchus  ;  and  sometimes  it  passes 
through  the  bronchus  into  one  of  its  subdivisions. 

The  immediate  effects  of  the  entrance  of  a  foreign  body  is 
usually  a  severe  paroxysm  of  pain  and  coughing,  with  more  or 
less  dyspnoea,  due  to  the  spasmodic  action  excited  in  the  laryn- 
geal muscles.  Sometimes  suffocation  takes  place  on  the  instant. 
The  sj'mptoms  of  an  accident  of  this  kind  are  thus  graphically 
described  by  Prof.  Gross  :  "  The  patient  is  seized  with  a  feeling 
of  annihilation ;  he  gasps  for  breath,  looks  wildly  around  him, 
coughs  violent!}^,  and  almost  loses  his  consciousness.  His  coun- 
tenance immediately  becomes  livid,  the  eyes  protrude  from  their 
sockets,  the  body  is  contorted  in  every  possible  manner,  and 
froth,  and  sometimes  even  blood,  issue  from  the  mouth  and 
nose.  Sometimes  he  grasps  his  throat,  and  utters  the  most  dis- 
tressing cries.  The  heart's  action  is  greatly  disturbed,  and  not 
unfrequently  the  individual  falls  down  in  a  state  of  insensibility, 
unable  to  execute  a  single  voluntary  function.  In  short,  he  is 
like  one  who  has  been  choked  by  the  hand,  or  by  the  rope  of 
the  executioner.  Sometimes  a  disposition  to  vomit,  or  actual 
vomiting,  occurs  immediately  after  the  accident,  especially  if  it 
take  place  soon  after  a  hearty  meal.  The  relief  occasionally 
experienced  from  this  source  is  very  great.  In  some  instances, 
again,  there  is  an  involuntary  discharge  of  faeces,  and  even  of 
urine." 


458        AFFECTIOIS'S    OF    THE    LAETKX    AND    TKACHEA. 

"  The  duration  of  the  first  paroxysms  varies  from  a  few  sec- 
onds to  several  minutes,  or,  in  severe  cases,  as  when  the  foreign 
body  is  arrested  in  the  larynx,  even  to  several  hours.  With  the 
restoration  of  the  respiration,  the  features  resume  their  natural 
appearance,  and  the  patient  recovers  his  consciousness  and 
power  of  sjDeech.  The  voice,  however,  fi*equently  remains  some- 
what altered,  the  breathing  is  more  or  less  embarrassed,  and  the 
individual  is  harassed  with  frequent  paroxysms  of  coughing,  at- 
tended often  with  a  recurrence  of  all,  or  nearly  all,  the  original 
symptoms.  Thus  the  case  may  progress  for  an  indefinite  period, 
until  the  foreign  body  is  expelled,  or  until  it  produces  death  by 
functional  or  organic  disease  of  the  air-passages." 

Sometimes  the  symptoms  are  very  slight,  and  under  these  cir- 
cumstances the  foreign  body,  when  hard  and  of  smooth  contour, 
may  remain  for  a  long  time  without  producing  injury.  I  have 
met  with  two  instances  of  such  sojourn  of  foreign  body  for  up- 
wards of  ten  years,  the  body,  in  one  instance  a  pebble,  being 
ejected  spontaneously  in  a  fit  of  coughing,  long  after  the  occur- 
rence of  the  accident  had  been  forgotten. 

The  effects  of  the  sojourn  of  a  foreign  body,  as  enumerated, 
and  discussed  in  detail  by  Prof.  Gross,  are  :  inflammation  of  the 
mucous  memljrane  of  the  larynx,  trachea  and  bronchi ;  some- 
times iuflammation  of  the  lungs,  and  this  inflammation  may  be 
followed  by  ulceration ;  the  formation  of  abscesses ;  a  deposit  of 
tuberculous  matter  ;  oedema  of  the  larpix  ;  pulmonary  emphy- 
sema ;  enlargement  and  softening  of  the  bronchial  lymphatic 
ganglions  ;  effusions  of  serum  and  lymph,  and  occasionally  of 
pus  in  the  pleura ;  extensive  adhesions,  and  sometimes  inflam- 
mation of  the  heart,  pericardium,  and  liver. 

When  a  foreign  body  has  been  retained  in  the  air-passages 
for  a  long  time  it  occasionally  becomes  encysted.  At  other 
times  it  is  expelled  through  the  mouth,  or  by  ulceration  through 
the  walls  of  the  chest. 

The  diagnosis  of  a  foreign  body  in  the  air-j^assages,  in  the 
absence  of  direct  history,  is  mainly  based  upon  the  suddenness  of 
the  onset  of  the  symptoms.  Auscultation  of  the  trachea  and  lungs 
also  assist  in  the  diagnosis;  in  the  first  instance  when  the  body 
is  loose,  and  in  the  latter  instance  when  it  is  impacted  in  one  of 


FOREIGN    BODIES    IN    THE    LAEYNX   AND    TRACHEA.    459 

the  bronchial  tubes.  All  the  spnptoms  of  a  foreign  body  in 
the  air-passages  may  be  produced  by  impaction  of  a  foreign 
body  in  the  pharynx  or  (Bsoj)hagus.  The  finger  and  the  oesopha- 
geal sound  will  determine  this  point  in  most  instances.  Care 
should  be  observed  in  these  examinations,  as  they  are  not  always 
unaccompanied  with  danger. 

Spontaneous  expulsion  of  the  foreign  body  often  takes  place, 
usually  followed  by  recovery,  but  sometimes  followed  by  death. 
Expulsion  is  often  produced  under  the  action  of  emetics  and 
errhines,  but  the  danger  of  producing  impaction  of  the  body 
within  the  larynx  presents  a  serious  objection  to  their  use. 

Inversion  of  the  body  and  succussion  of  the  chest  and  back  is 
liable  to  the  same  danger  of  producing  impaction.  Still,  these 
methods  have  proved  successful  in  many  instances. 

The  proper  treatment  for  a  case  of  foreign  body  in  the  air- 
passage  consists  in  making  an  artificial  opening  below  the  glot- 
tis in  order  to  afford  the  best  chance  for  the  expulsion  or  extrac- 
tion of  the  body,  and  to  avoid  the  danger  of  suffocation  by 
spasm  of  tlie  glottis.  An  operation  of  this  kind  may  become  a 
serious  matter  if  there  exist  any  considerable  pulmonary  com- 
plication. Laryngotomy  is  preferred  in  the  adult  when  it  is  evi- 
dent that  the  foreign  body  is  in  the  larynx.  Sometimes,  though 
rarely,  more  or  less  complete  division  of  the  thyroid  cartilage  is 
required,  as,  for  instance^  when  the  body  is  impacted  in  one  of 
the  ventricles  of  the  larynx  and  cannot  be  dislodged  through 
the  wound  in  the  crico-thyroid  membrane.  In  cases  of  foreign 
body  in  the  trachea,  and  also  in  most  cases  occurring  in  small 
children,  the  operation  of  tracheotomy  is  to  be  preferred,  as  ad- 
mitting of  a  larger  opening  and  the  freer  play  of  instruments 
passed  through  it.  The  opening  should  be  sufficiently  large  to 
permit  the  ready  escape  of  the  foreign  body,  and  should  in  all 
cases  exceed  the  length  of  the  glottis  of  the  individual.  At  least 
one  inch  and  a  quarter  in  the  adult,  and  not  less  than  one  inch 
in  the  child,  is  the  rule  laid  down  by  Prof.  Gross. 

Very  often,  as  soon  as  the  air-passage  is  open,  the  foreign 
body  is  ejected,  in  a  fit  of  coughing,  from  the  wound  or  fi'om 
the  glottis,  aud  under  the  latter  circumstances  it  may  lodge  in  the 
mouth  or  pass  down  the  oesophagus.     At  other  times  it  presents 


460        AFFECTIOIS^S    OF   THE    LAEYISTX    AjS^D    TRACHEA. 

at  the  lips  of  the  wound,  whence  it  is  readily  extracted  with 
forceps.  If  the  foreign  body  does  not  move  towards  the  exte- 
rior, it  is  customary  to  turn  the  patient  upon  the  face  and  to 
strike  the  chest  or  back  with  the  hand.  It  has  also  been  recom- 
mended to  blow  strongly  into  the  wound  so  as  to  compress  the 
air  within  the  trachea,  that  it  may  gather  expulsive  force  in 
the  coughing  which  follows. 

If  these  manoeuvres  do  not  succeed  in  the  expulsion  of  the 
body,  instruments  must  be  passed  into  the  air-tube  for  that  pur- 
pose. Great  care  should  be  taken  in  manipulations  of  this  kind, 
as  they  usually  provoke  violent  paroxysms  of  cough,  and  in  this 
way  endanger  the  mucous  membrane  of  the  parts.  All  instru- 
ments ought  to  be  warmed  before  being  passed  into  the  trachea, 
as  they  will  be  much  less  likely  to  cause  severe  spasm  than  the 
contact  of  cold  instruments.  The  instrument  employed  will 
vary  with  the  nature  of  the  case  and  the  resources  of  the  sur- 
geon. A  long  bent  probe  with  a  blunt  hooked  extremity  will 
often  be  of  service.  So  also  a  pair  of  delicate  curved  forceps, 
such  as  are  used  for  toi-sion  of  nasal  polyps.  I  have  used  the 
curved  portion  of  the  laryngeal  forceps  with  success.  Whatever 
instniment  is  used  should  be  first  employed  as  a  sound  until  the 
location  of  the  foreign  body  is  discovered,  when  suitable  efforts 
may  be  made  at  extraction.  Wlien  the  body  lies  at  the  com- 
mencement of  one  of  the  bronchi,  care  must  be  taken  that  it  is 
not  pushed  farther  on  in  the  manipulation.  Under  these  cir- 
cumstances a  stout  wire,  terminating  in  a  small  bhmt  hook,  may 
be  insinuated  past  the  body  and  then  drawn  upon  to  dislodge 
it,  when  it  will  be  likely  to  be  coughed  out  or'  coughed  within 
grasp  of  the  forceps  at  the  seat  of  the  wound.  Efforts  at  extrac- 
tion sliould  not  be  prolonged  for  many  minutes.  It  is  much  bet- 
ter practice  to  keep  the  wound  oj)en  by  hooks,  or  by  ligatures 
passed  through  its  edges  and  fastened  round  the  neck,  and  to 
repeat  the  efforts  at  removal  in  a  few  hours  or  upon  the  follow- 
in  <>•  dav.  Meanwhile  the  wound  should  be  covered  by  a  fold  of 
thin  muslin  to  modify  the  temperature  of  the  air.  Yery  often 
the  foreign  body  is  expelled  through  the  wound  thus  left  open, 
durino:  the  absence  of  the  surgeon. 

Tiie  wound  should  be  kept  open  until  the  foreign  body  has 


APHONIA.  461 

been  expelled ;  and  if  this  does  not  take  place  for  a  long  time,  a 
canula  may  be  worn  to  keep  it  patulous;  but  under  ordinary  cir- 
cumstances the  canula  will  be  in  the  way  and  prevent  the  ex- 
pulsion of  a  foreign  body  situated  below  it.  Under  these  cir- 
cumstances, should  there  arise  any  evidence  of  the  dislodgment 
of  the  body,  the  canula  should  be  promptly  withdrawn  to  give 
it  chance  to  escape. 

As  long  as  the  wound  is  kept  open,  the  air  of  the  apartment 
in  which  the  patient  resides  should  be  kept  warm  and  moist  by 
the  evaporation  of  steam.  When  the  foreign  body  has  been 
expelled,  or  when  from  other  reasons  it  is  deemed  desirable 
to  close  the  aperture,  the  edges  of  the  cutaneous  wound  are 
brought  together  by  adhesive  strips,  and  sutures  if  necessary.  A 
simple  dry  dressing  is  usually  all  that  is  requisite.  The  wound 
usually  heals  kindly  in  a  few  days,  unless  kept  patulous  in  part 
by  convulsive  or  catarrhal  cough  and  the  escape  of  air,  nnder 
which  circumstance  a  permanent  tracheal  fistule  is  sometimes 
produced. 

AI'HONIA. 

Aphonia,  or  complete  loss  of  voice,  occurs  in  connection  with 
various  laryngeal  affections  of  inflammatory  origin,  and  is  the 
result  of  a  mechanical  impediment  to  the  approximation  of  the 
vocal  cords,  such  as  cicatrization,  the  presence  of  a  tumor,  or  a 
condition  of  swelling  in  the  arytenoid  cartilages  or  in  other  struc- 
tures, preventing  the  apposition  of  these  parts  in  attempts  at  pho- 
nation.  Sometimes  there  is  an  impediment  due  to  vibration  of  the 
cords  in  consequence  of  the  pressure  upon  them  of  a  tumor,  or  of 
swollen  ventricular  bands.  When  the  loss  of  voice  is  incomplete, 
it  is  designated  as  dysphonia,  a  term  synonymous  with  raucitas  or 
hoarseness ;  and  this  modification  of  voice  is  attendant,  in  some 
degree  or  other,  upon  almost  all  diseases  of  the  larynx.  These 
forms  of  defective  voice  have  already  been  discussed,  in  part,  in 
counection  with  the  consideration  of  the  diseases  in  which  they 
occur.  They  are  designated  as  organic  aphonia,  or  aphonia  with 
apparent  cause.  There  are,  however,  other  forms  of  organic 
aphonia  very  liable  to  be  confounded  with  still  another  form  of 
the  affection  occurring  without  apparent  cause,  and  denominated 


462         AFFECTIOI^S    OF    THE    LAEYITX    AND    TRACHEA. 

functional  aphonia ;  these  examples  of  organic  aphonia  occurring 
in  connection  with  morbid  growths,  aneurisms,  and  other  tumors 
outside  of  the  larynx,  pressing  upon  the  laryngeal  recurrent 
nerve,  and  thus  paralyzing  the  vocal  muscles.  Still  another  form 
of  organic  aphonia,  also  confounded  with  functional  aphonia, 
exists  in  certain  cases  of  cerebral  disease,  metallic  poisoning, 
etc.,  in  which  the  spinal  accessory  nerve  is  paralyzed,  and,  as  a 
matter  of  course,  the  recurrent  laryngeal  fibres  in  it. 

A  form  of  aphonia  occurring  independently  of  organic  dis- 
ease is  frequently  met  with,  and  is  often  denominated  fimctional 
aphonia,  or  nervous  aphonia.  In  these  cases  there  is  paralysis 
of  some  of  the  muscles  attached  to  the  vocal  cords,  preventing 
their  approximation,  or  their  due  tension  when  in  apposition, 
and  thus  destroying  the  physical  conditions  on  which  the  for- 
mation of  the  voice  depends. 

Cases  of  this  kind  occur  very  frequently  in  connection  with 
hysteria,  and  most  frequently  in  females  ;  but  they  are  by  no 
means  confined  to  subjects  of  hysteria. 

The  physical  and  immediate  cause  of  aphonia  in  the  in- 
stances referred  to  will  be  readily  comprehended  by  a  cursory 
glance  at  the  subject  of  the  formation  of  the  voice.  The  sole 
factors  of  voice  are  the  lower  or  true  vocal  cords  ;  or  the  vocal 
cords,  as  they  have  been  denominated  in  this  volume  ;  the  false 
vocal  cords  being  called  ventTicular  hands,  in  compliance  with 
transatlantic  nomenclature.  These  vocal  cords,  one  on  either 
side,  are  membranous  reeds  which  become  approximated  in 
vocalization,  so  that  a  very  narrow  slit  between  tliem  affords  the 
only  passage  for  the  expiratory  current  of  air.  This  current  of 
air  as  it  passes  between  the  tense  membranes  sets  them  in 
vibration,  exactly  on  the  same  principle  that  the  current  of  air 
from  the  bellows  of  the  accordion  sets  the  reeds  of  that  instru- 
ment in  vibration. 

The  following  figures  from  Czermak,'  and  boiTOwed  from 
Bennett,  will  roughly  illustrate  the  appearance  of  the  cords 
before  phonation,  and  during  phonation  when  they  are  brouglit 
together  and  rendered  tense  by  the  combined   action  of  tlie 

'  Der  Kehlkopf Spiegel,  Leipzig,  1863. 


APHOlSriA. 


463 


various  laryngeal  muscles.  The  vocal  cords  are  in  contact  an- 
teriorly by  the  vocal  processes  of  the  middle  plate  of  the  thyroid 
cartilage.  In  phonation  they  are  brought  together  posteriorly 
by  the  action  of  the  transverse  and  oblique  fibres  of  the  aryte- 
noid muscle ;  they  are  rendered  tense  and  stretched  vertically 
by  the  action  of  the  crico-thyroid  muscle ;  they  are  stretched 
transversely  and  shortened  by  the  thyro-arytenoid  muscles  ;  and 
they  are  slackened  and  shortened  by  the  action  of  the  lateral 
crico-arytenoid  muscles.  When  these  muscles  relax,  the  cords 
are   separated  by  the  action  of  the  posterior   crico-arytenoid 


Fig.  108. 


Fig.  109. 


Appearance  of  larynx  as  vocalization  is  about 

Appearance  of  the  glottis  in  vocalization. 

to  commence  (after  Czermak). 

(Czermak.) 

1.  Base  of  tongue. 

1.  Base  of  tongue. 

2.  CEsophageal  entrance. 

4.  Epiglottis. 

3.  Aryteno-epiglottic  fold. 

6.  Pad  of  epiglottis. 

4.  Epiglottis. 

7.  Aryteno-epiglottic  fold. 

6.  Pad,  or  belly  of  epiglottis. 

9.  Cartilage  of  Santormi. 

8.  Cartilage  of  "Wrisberg. 

12.  Vocal  cord. 

9,  10.  Cartilage  of  Santorini. 

1-3.  Ventricular  band. 

11.  Vocal  process. 

14.  Ventricle. 

12.  Vocal  cord. 

13.  Ventricular  band. 

14.  Ventricle. 

muscles.  These  effects  can  be  produced  in  the  exsected  larynx 
by  electricity,  or  be  perceived  in  the  living  larynx  by  means  of 
the  laryngoscope. 

It  may  not  be  amiss  here,  as  a  guide  in  the  study  of  defects 
of  voice,  to  indicate  the  physical  condition  of  the  vocal  cords  in 
the  rise  in  pitch  and  in  the  formation  of  the  chest,  falsetto,  and 
liead-registers  of  the  human  voice. 

The  rise  in  pitch  is  due  to  a  stretching  and  shortening  of  the 
cords.  This  is  done  on  either  side  by  the  action  of  the  lateral 
crico-arytenoid  muscle,  which  draws  the  arytenoid  cartilage 
forward   and   outward,  thus   turning  the    vocal   processes  in- 


464        AFFECTIO]SrS    OF    THE    LARYNX    AND    TPwACHEA. 

ward,  and  sti^etching  the  cords  posteriorly.  At  the  same 
time  the  crico-thyroid  muscle,  drawing  the  thyroid  cartilage 
down  upon  the  cricoid  with  a  forward  rotary  motion,  stretches 
the  cord  anteriorly.  While  the  cords  are  being  stretched 
in  their  length  in  tliis  manner,  the  thyro-arytenoid  muscle 
to  which  the  outer  portion  of  the  cord  is  inseparably  at- 
tached, and  which  may  be  called  the  vocal  muscle  jpar  ex- 
cellence^ stretches  the  cord  laterally,  thus  rendering  it  tense 
enough  to  act  as  a  reed  and  to  be  set  into  vibration  by  the 
passage  of  the  current  of  air.  The  complexity  of  this  muscle 
is  such  that,  by  a  partial  action  of  one  set  of  fibres,  it  produces 
a  slight  bulging  upward  or  vaulting  of  the  vocal  cords,  and 
assists  in  their  shortening. 

When  the  action  of  the  parts  is  viewed  in  the  laryngoscope 
during  the  emission  of  the  chest  register,  we  see  the  arytenoid 
muscle  contract  and  compress  the  arytenoid  cartilages  together ; 
and,  as  the  voice  rises  in  the  scale,  the  arytenoid  muscle 
gradually  contracts  more  and  more,  shortening  the  chink  of  the 
glottis,  which  is  still  further  gradually  shortened  anteriorly  by 
the  increasing  contraction  of  the  anterior  fibres  of  the  thyro- 
arytenoids. This  occurs  more  and  more  at  every  higher  note, 
until  a  point  is  reached  at  which,  if  this  action  is  continued,  the 
vocal  cords  become  congested,  showing  that  there  is  now  undue 
tension ;  and  this  point  marks  the  natural  limit  of  the  chest 
register.  During  all  this  time  the  vocal  cords  vibrate  in  their 
entire  hreadth,  and  this  constitutes  the  essential  feature  of  this 
chest  register. 

In  the  formation  of  the  falsetto  register,  the  glottis  again 
lengthens  as  before,  the  vocal  cords  seeming  longer  than  during 
the  formation  of  the  chest  tones,  and  less  vaulted  in  form.  As 
the  higher  notes  are  produced,  a  similar  action  of  shortening 
occurs  to  that  already  described,  until  a  point  is  again  reached 
where  signs  of  congestion  appear,  marking  the  upper  limit  of 
this  register.  During  all  these  notes  the  edges  alone  of  the 
vocal  cords  are  in  vibration,  constituting  the  essential  feature 
of  the  falsetto  register. 

In  the  production  of  the  head  tones,  which  are  only  produced 
in  larynges  whose  arytenoid  cartilages   have  very  long  vocal 


APHONIA. 


465 


processes,  these  vocal  processes  become  tiglitly  compressed 
XogQ\}ii&Y,GOin])letely  closing  the  jposterior  jportion  of  the  glottis^ 
so  that  there  remains  open  only  a  slender  ellijjtical  fissure 
anteriorly,  which  seems  to  occupy  but  Httle  more  than  one-half 
of  the  length  of  the  cords,  and  during  the  emission  of  the  voice 
the  edges  of  this  oval  opening  vibrate.  This  coonplete  closure 
of  nearly  the  entire  half  of  the  glottis  jposteriorly  constitutes  the 
peculiarity  of  the  head  voice. 

With  this  digression  on  an  imperfectly  understood  portion  of 
physiology  we  can  better  understand  the  varieties  of  nervous  or 
paralytic  aphonia  which  are  met  with  in  practice,  and  which 
are  usually  termed  functional  aphonia. 

Paralytic  aphonia  may  in\'olve  both  cords  or  only  one.  In  the 
latter  case  the  voice  is  not  always  entirely  lost,  there  being  often 
a  condition  of  dysphonia  merely.  The  condition  in  the  laryn- 
goscope is  very  marked.  The  sound  cord  approaches  the 
middle  line  in  an  attempt  at  phdnation,  but  the  paralyzed  cord 
does  not  move  to  meet  it.  In  some  instances  the  sound  cord 
crosses  the  middle  line  and  approaches  the  paralyzed  cord 
sufficiently  to  satisfy  the  physical  conditions  necessary  to  insure 
vibration,  and  it  is  in  such  instances  that  we  ha,ve  a  rough, 
imperfect  voice.     Occasionally,  the  voice  will   remain  almost 

Fig.  119.  Fig.  130. 


Paralysis  of  left  vocal  cord  in  a  case 
of  phthisis.  Appearance  during  res- 
piration. 


Paralysis  of  left  vocal  cord  in  a  case 
of  phthisis.  Appearance  during  at- 
tempt at  phonation. 


natural  in  intensity,  pitch,  and  quality,  and  give  rise  only  to  a  loss 
of  power  of  modulation.  Cases  of  this  kind  are,  according  to 
the  author's  experience,  almost  always  connected  with  cerebral 
disease,  phthisis,  metallic  poisoning,  or  the  pressure  of  an 
aneurismal  or  other  tumor  upon  the  inferior  laryngeal  nerve. 
In  the  cases  of  phthisis,  the  paralysis  will  be  almost  always 
30 


466       AFFECTIOXS    OF    THE    LARTjS^X   AND    TRACHEA. 

observed  on  tlie  same  side  as  that  wliicli  is  the  seat  of  the 
earliest  deposit. 

Figs.  119  and  120  represent  one  of  the  anthor's  cases  of  para- 
lysis of  the  left  vocal  cord  occurring  in  phthisis,  and  producing 
aphonia.  Eig.  119  represents  the  parts  during  expiration,  and 
Fig.  120  their  appearance  in  phonation,  in  which  it  will  be  seen 
that  the  right  cord  slightly  passes  the  middle  line.  An 
"ulceration  is  seen  upon  the  ventricular  band  of  the  same  side, 
and  the  mucous  membrane  covering  the  corpuscle  of  Santorini 
of  the  same  side,  is  swollen  from  sub-mucous  infiltration. 

Figs.  121  and  122  sketch  a  somewhat  similar  condition 
occurring  in  a  case  of  aneurism  of  the  arch  of  the  aorta,  and 
also  attended  by  aphonia. 

Fig.  121.  _.   _  Fig.  122. 


Paralysis  of  left  vocal  cord  in  a  case  Paralysis  of  left  vocal  cord  in  a  case 

of  aneurism  of  the  aorta.     Appearance  of  aneurism  of  the  aorta.    Appearance 

during  respiration.  during  attempted  phonation. 

Fig.  121  represents  the  parts  in  ordinary  respiration,  and 
Fig.  122  the  same  parts  in  attempts  at  vocalization.  Both  these 
cases  terminated  fatally :  the  first  in  the  ordinary  slow  course  of 
consumption ;  and  the  latter  suddenly,  by  hemorrhage,  fi-om 
rupture  of  the  aneurism  into  the  pulmonary  artery. 

Cases  of  this  kind  are  usually  incurable.  Certainly  they 
are  not  to  be  remedied  by  local  measures  instituted  with 
reference  to  the  affection  of  the  voice;  although  in  many 
instances,  as  in  the  two  cases  selected  for  illustration,  it  is  the 
loss  of  voice  that  first  suggests  the  idea  of  the  existence  of 
disease  of  a  serious  character. 

Dysphonia  is  occasionally  produced  by  the  operation  of 
ligating  the  primitive  carotid  artery,  the  surgeon  having  in- 
cluded in  his  ligature  a  little  nervous  twig  which  leaves  the 


APHONTA. 


467 


superior  laryngeal  nerve  just  before  its  division  into  the  two 
branches,  one  of  which  passes  to  the  external  face  of  the  wing 
of  the  thyroid  cartilage,  and  tlie  other  to  the  internal  face.  This 
twig,  which  often  increases  the  thickness  of  the  gangliform 
plexus  of  the  pneumogastric,  runs  along  the  middle  circumfer- 
ence of  the  primitive  carotid  artery,  and  thence  sends  a  twig 
to  the  intercarotid  plexus,  which  finally  loses  itself  in  the 
branches  of  that  vessel.  If,  therefore,  the  voice  is  altered  after 
an  operation  upon  the  primitive  carotid,  the  surgeon  can  infer 
that  he  has  included  this  twig  in  his  ligature. 

Paralysis  of  both  cords  may  be  peripheral  or  central ;  that 
is  to  say,  it  may  proceed  fi-om  disease  of  the  nerve  centres,  in 
which  it  is,  as  a  rule,  irremediable  by  local  measures ;  or  it  may 
be  due  to  defective  innervation  at  the  points  of  ultimate  dis- 
tribution ;  a  condition  much  more  frequent,  and  one  which  is 
nearly  always  promptly  amenable  to  local  treatment. 

These  forms  of  paralysis  of  both  cords  may  vary  in  several 


Pig.  123. 


Fig.  124. 


Aphonia,    wltti   motnen-  Complete  paralysis  of  both  cords.  Paralysis    of  thyro-ary- 


tary  normal  closure  of  glot- 
tis. Also  represents  apho- 
nia with  normal  closure, 
but  want  of  vibration  of  one 
or  both  cords.    (Tobold.) 


(Tobold.) 

a  a  arytenoid  cartilages ;  h  poste- 
rior wall  of  larjTix ;  ss  vocal  process 
of  the  arytenoid  cartilages. 


tenoid  muscles.  Closure 
of  the  inter-arytenoidal 
space  of  the  glottis,  that 
portion  between  the  vocal 
cords  remaining  open. 
(Tobold.) 


particulars.     Tobold  ^  designates  five  forms,  as  illustrated  in  the 
accompanying  diagrams : 


1  Die  Chronischen  Kehlkopf-Krankheiten.     Berlin,  1866. 


468       AFFECTIOlSrS    OF   THE   LAEYISTX   AND    TEACHEA. 

-Fig.  123  represents  a  normal  closure  of  the  glottis,  with  a 
want  of  innervation  in  the  arj^tenoicl  muscles,  which  leads  to  an 
immediate  separation  posteriorly,  so  that  the  glottis  assumes  the 
form  depicted  in  Fig.  127.  This  form  is  usually  longer  of  cure 
than  the  others.  Fig.  123  also  represents  normal  closure  of 
glottis,  with  want  of  vibration  of  one  or  both  cords. 

Fig.  124  represents  the  most  common  form,  in  which  the  vocal 
cords  remain  separated  without  any  appearance  of  coming 
together.  The  paralysis  is  in  the  posterior  arytenoid  muscle 
and  the  thyro-arytenoids. 

Another  form  of  the  paralysis  is  depicted  in  Fig.  125,  Here 
the  arytenoid  muscles  bi'ing  the  arytenoids  into  contact,  but  the 
whole  anterior  portion  of  the  glottis  remains  open,  and  aphonia 
results.  The  paralysis  affects  the  thyro-arytenoid  muscles,  and 
in  some  instances  the  crico-thyroids  also. 


Fig.  126. 


Fig.  127 


Elliptical  opening  of  entire  glottis. 
(Tobold.) 


Want  of  approximation  of  the  arytenoid 
cartilages.     (Tobold.) 


Still  another  form  of  paralysis  of  both  cords  is  depicted  in 
Fig.  126.  Here  the  entire  glottis  has  the  form  of  an  ellipse. 
The  posterior  arytenoid  muscle  brings  these  arytenoids  in  con- 
tact posteriorly,  but  they  cannot  rotate  so  that  their  vocal  pro- 
cesses come  in  contact.  There  is  here  paralysis  of  the  lateral 
crico-arytenoid  muscles  and  of  the  thyro-arytenoids. 

Finally,  Fig.  127  represents  a  quite  common  form  of  paralysis, 


APHOisriA.  469 

affecting  the  arytenoid  muscle  only,  and  perhaps  its  traiisyerse 
fibres  chiefij.  This  form  often  permits  of  a  certain  amount  of 
phonation. 

There  is  still  another  form  not  infrequently  met  with,  and 
that  is  whei-e  there  is  a  normal  closure  of  the  glottis  comprised 
within  the  Tocal  cords,  but  opening  behind  the  point  of  contact 
of  the  vocal  processes  of  the  arytenoid  cartilages.  This  is  due 
to  paralysis  of  the  arytenoid  muscle  only.  In  this  variety,  too, 
the  voice  is  usually  dysphonic  only ;  but  sometimes  it  is  com- 
pletely aphonic. 

In  addition  to  all  this,  there  is  another  form  of  bilateral  para- 
lysis, very  serious  in  regard  to  life,  which  consists  in  paralysis 
of  the  posterior  crico-arytenoid  muscles,  preventing  proper 
opening  of  the  glottis,  and  thus  threatening  suffocation.  It  is 
readily  recognized  in  the  laryngoscope,  and  the  subjective  symp- 
toms are  similar  to  those  of  laryngismus  stridulus.  There  is  no 
aphonia,  because  there  is  no  difficulty  in  bringing  the  cords 
together ;  the  difficulty  lies  with  drawing  them  aj^art.  Trache- 
otomy is  called  for  in  this  affection,  which  is  mentioned  in  this 
connection  on  account  of  its  being  due  to  paralysis,  a  condition 
which,  as  a  rule,  affects  the  laryngeal  muscles  of  contraction 
of  the  glottis,  and  not  those  of  dilatation. 

The  cause  of  parahtic  aphonia  is  sometimes  involved  in  ob- 
scurity. A  certain  number  of  cases  occur  as  one  of  the  mani- 
festations of  hysteria.  Others  occur  as  reflex  actions  fi-om  the 
irritation  of  laryngeal,  tracheal,  or  bronchial  catarrh ;  the  catarrh 
of  scarlatina,  measles,  and  small-pox ;  rheumatism  ;  syphilis  ; 
scorbutis ;  scrofulous  inflammations  elsewhere ;  dyspepsia,  from 
the  abuse  of  warm  drinks,  and  rich,  greasy  food ;  worms  in  the 
alimentary  canal ;  displacements  and  other  disturbances  of  the 
uterus.  Xot  infrequently  the  paralysis  results  fi'oin  overwork, 
or  too  constant  use  of  the  voice  by  professionals.  Many  of  our 
famous  opera  singers  have  lost  their  voices  at  some  time  or  other 
from  this  cause,  the  immense  prices  paid  for  their  services  stimu- 
lating them  to  sing  night  after  night  upon  an  illy-warmed  stage 
during  a  long  season.  Madame  Talma  was  known  to  have  been 
compelled  to  quit  the  scenes  on  this  account ;  though  it  is  rare 
that  the  aphonia  occurs  dm-ing  the  excitement  of  public  sing- 


470       AFFECTIONS    OF   THE   LARYNX   AND    TEACHEA. 

ing.  Mental  emotion  sometimes  produces  aphonia,  independ- 
ently of  any  hysterical  condition  or  nndue  nervousness.  One  of 
the  cases  which  came  under  my  care  occurred  in  a  married  lady, 
intelligent,  and  apparently  sound  in  mind  and  body,  who  lost  her 
voice  several  years  before  under  the  following  circumstances. 
She  was  residing  in  the  country,  and  received  an  urgent  message 
to  visit  her  parents'  home,  as  her  father,  to  whom  she  was  much 
attached,  lay  very  ill.  On  her  arrival  she  was  met  by  the  phy- 
sician, who  explained  to  her  that  her  father  was  dying.  On 
entering  her  father's  room,  and  realizing  his  condition,  she  was 
unable  to  speak  to  him,  though  her  voice  had  been  as  good  as 
ever  the  moment  before,  and  had  survived  the  shock  of  the 
mournful  intelligence.  This  condition  had  persisted  for  three 
or  four  years  in  spite  of  treatment. 

The  treatment  of  aphonia,  or  dysphonia,  due  to  paralysis 
of  the  vocal  cords,  depends  upon  the  nature  of  the  lesion, 
and  the  constitutional  condition  of  the  patient.  Paralysis  of 
both  cords,  when  not  dependent  upon  lesion  of  the  nerve  cen- 
tres, or  upon  pressure  upon  the  nerve  in  some  part  of  its  course, 
is  almost  always  susceptible  of  prompt  cure,  even  when  the 
aphonia  has  existed  for  many  years.  This  is  particularly  the 
case  in  hysterical  aphonia,  but  it  is  true  also  of  aphonia  not  asso- 
ciated with  hysteria.  In  many  instances  of  hysterical  aphonia 
the  voice  is  lost  suddenly,  and  as  suddenly  regained,  it  may  be 
in  a  few  hours,  in  a  few  days  or  weeks,  or  after  several  months 
or  even  years. 

The  cases  of  this  kind  whicli  have  occurred  in  the  author's 
experience  can  be  counted  in  hundreds,  in  man}^  of  which  he  has 
found  tliat  the  voice  may  be  readily  restored  by  any  stimulus 
directly  applied  to  the  glottis  ;  most  frequently  by  the  produc- 
tion of  spasmodic  action  of  the  vocal  cords,  but  in  some  instances 
by  the  emotion  produced  in  the  mind  of  the  individual.  The 
methods  employed  for  this  purpose  have  been  various,  often  in- 
different, and  sometimes  selected  at  random  for  the  purpose  of 
testing  the  point.  They  have  been  such  as  inhalation  of  the  va- 
pors of  chlorine,  of  iodine,  of  ammonia  ;  the  direct  application 
to  the  glottis  of  cold  water,  tincture  of  iodine,  nitrate  of  silver, 
etc.,  by  means  of  the  sponge  probang;  the  injection  of  sprays  of 


APHONIA. 


471 


ice-water,  sulphuric  ether,  sulphate  of  zinc,  etc.,  by  means  of  the 
laryngeal  syringe.  In  quite  a  large  number  of  instances,  in  one 
of  which  complete  aphonia  had  existed  continuously  for  more 
than  four  years,  I  have  succeeded  in  restoring  the  voice  by  the 
simple  introduction  of  the  laryngeal  mirror,  the  patient  being 
purposely  impressed  with  the  idea  that  this  manipulation  con- 
stituted the  operative  procedure.  In  fact  this  is  the  method  I 
adopt  in  cases  of  habitual  loss  of  voice,  and  often  find  it  instan- 
taneously effective.  Where  simple  introduction  of  the  mirror 
does  not  suifice,  recourse  is  had  to  some  of  the  methods  above 
narrated ;  and  if  these  are  not  promptly  successful,  resort  is 
made  to  the  passage  of  an  electric  current  through  the  parts,  the 
negative  pole  being  brought  in  contact  with  the  vocal  cords,  or 
with  the  muscles  at  fault,  and  the  positive  pole  being  placed  at 
an  indifferent  place  upon  the  cutaneous  surface,  that  is  to  say  in 


Fig.  128. 


Mackenzie's  laryngeal  electrodes. 

the  hand  of  the  patient,  or  upon  the  neck  just  over  the  seat  of 
the  crico-thyroid  membrane.  This  method  of  local  electriza- 
tion is  exceedingly  effective,  and  rarely  fails  even  in  obstinate 
cases.  It  was  introduced  into  the  treatment  of  aphonia  by  Dr. 
Mackenzie,  who  has  devised  special  electrodes  for  the  purpose, 
the  most  useful  of  which  are  illustrated  in  Fig.  128. 

The  upper  figure  represents  an  isolated  electrode  to  be  placed 
witliin  the  larynx,  a  bit  of  sponge  or  leather  being  fastened  upon 
the  exposed  bulb  to  prevent  the  stinging  or  burning  sensation 
that  accompanies  the  uncovered  instrument.  The  conducting 
wire  from  the  battery  is  attached  to  a  metallic  ring,-  which  en- 
circles a  glass  handle  ;  this  metalHc  ring  is  brought  in  contact 


472   AFFECTIONS  OF  THE  LAEYNX  AND  TEACHEA. 

with  the  laryngeal  portion  of  the  instrument  by  pressing  a  me- 
tallic spring  interrupter  upon  it.  In  this  manner  the  passage  of 
the  cm-rent  is  controlled,  and  when  the  spring  is  not  pressed  the 
instrument  is  a  simple  probe  or  sound.  The  lower  figure  repre- 
sents a  sponge  electrode,  which  is  to  be  placed  on  the  outside  of 
the  neck  and  held  by  the  patient  or  an  assistant.  Dr.  Mackenzie 
prefers  for  this  purpose  a  sponge  electrode  more  recently  devised 
by  him,  attached  to  a  collar  which  is  secured  round  the  neck  of 
the  patient,  who  in  this  way  is  attached  to  the  battery  by  the  con- 
ducting wire.  The  larjmgeal  electrode  has  been  modified  by  Drs. 
Mackenzie,  Tobold,  and  others,  so  as  to  branch  into  two  di\-isions, 
one  of  which  can  be  placed  on  each  vocal  cord  ;  or  one  outside 
of  ^the  laryngeal  wall  and  the  other  within.  In  similar  manner 
the  electrode  has  been  made  of  two  isolated  rods,  one  of  which  is 
placed  in  connection  with  each  pole  of  the  battery. 

In  order  to  avoid  exciting  the  muscles  of  the  pharynx  into  con- 
traction when  employing  Mackenzie's  laryngeal  electrode  upon 
the  pharyngeal  surface  of  the  larynx,  as,  for  example,  when 
placing  it  over  the  arytenoid  muscle,  it  is  well  to  unscrew  the 
metallic  iDulb,  and  replace  it  by  a  thin  curved  plate,  tlie  convex 
portion  of  which  is  insulated  by  a  layer  of  hard  rubber.  The 
plate  being  perforated,  a  thin  strip  of  sponge  is  sewed  on  with 
silk. 

Any  galvanic  batterj',  induction  coil,  or  magneto-electric  ma- 
chine, may,  as  a  rule,  be  used  as  the  source  of  electricity,  this 
being  usually,  in  these  cases,  a  matter  of  indifference ;  a  fact 
which  goes  a  good  way  to  prove  that  it  is  not  the  electrical  cur- 
rent in  itself  which  produces  the  result,  but  the  stimulus  con- 
veyed to  the  part  by  the  electric  shocks.  In  this  way,  too,  we 
can  explain  the  success  of  intra-laryngeal  applications  of  elec- 
tricity in  cases  where  external  applications  fail.  In  cases  where 
the  electric  treatment  is  prominently  indicated,  we  sometimes 
find  that  the  few  seconds  at  a  time  during  which  the  current 
can  be  borne  within  the  larynx,  is  insufiicient  for  securing  the 
.passage  of  a  sufiicient  amount  of  electricity  through  the  para- 
lyzed parts  ;  and  under  these  circumstances  we  are  often  able 
to  succeed  with  protracted  electrization  practised  externally,  even 
after  the  unsuccessful  resort  to.  the  intra-laiyngeal  method.     In 


APHO]sriA.  473 

the  external  method  we  may  place  one  pole  in  front  of  the  crico- 
thyroid ligament,  and  the  other  to  the  nape  of  the  neck ;  or  we 
may  pass  the  current  through  the  thjToid  cartilage  fi'om  side  to 
side  ;  or  we  may  place  one  pole  over  the  crico-thyroid  membrane 
or  at  the  side  of  the  neck,  and  the  other  in  the  hand.  We  use 
the  negative  electrode  at  the  point  nearest  the  larjmgeal  muscles, 
endeavoring  to  cover  them  where  possible  ;  and  where  this  is 
not  successful  we  place  a  pointed  electrode,  similar  to  the  upper 
one  in  Fig.  128,  along  the  side  of  the  trachea  as  near  as  possible 
to  the  course  traversed  by  the  inferior  laryngeal  nerve ;  or  we 
may  take  this  electrode  and  pass  it  down  the  oesophagus,  by  the 
side  of  the  larynx,  in  order  the  better  to  act  on  this  same  nerve. 

The  treatment  of  aphonia  by  local  electrization  is  to  be  con- 
tinued every  day  or  every  other  day  until  the  voice  has  returned. 
This  result  will  not  infrecjuently  happen  at  the  very  first  apph- 
cation.  When  the  voice  has  retm-ned  it  will  be  prudent  to  con- 
tinue the  treatment,  at  gradually  lengthened  intervals,  for  two, 
three,  or  four  weeks,  or  until  the  voice  has  gained  its  original 
strength.  Four  or  five  applications  of  a  few  seconds'  duration 
each  are  made  at  each  interview.  But,  even  without  any  fur- 
ther treatment,  the  voice  often  remains  good  after  it  has  once 
been  restored  in  this  way. 

In  certain  cases  relapses  take  place,  and  they  are  to  be  treated 
in  the  same  way  as  at  first.  Meanwhile,  attention  should  be 
paid  to  the  general  liealth ;  and  such  constitutional  treatment 
be  adopted  as  may  be  requisite.  A  salt  of  strychnine  is  particu- 
larly indicated,  and  forms  an  admirable  addition  to  the  general 
tonic  treatment.  In  some  cases,  and  perhaps  in  a  great  many  of 
them,  if  it  were  more  resorted  to,  it  is  adequate  to  a  cure  with- 
out the  institution  of  any  local  measm-es.  Injected  hypoder- 
mically,  in  doses  commencing  at  -g^^  of  a  grain,  and  increased, 
the  sulphate  or  the  nitrate  of  strychnia  will  often  act  most  hap- 
pily after  a  few  injections, repeated  at  intervals  of  three  or  four 
days.  It  cannot  always  be  relied  upon.  I  have  employed  it  in 
this  manner  in  much  larger  doses  ;  and  internally  in  doses  gradu- 
ally augmented  to  J  grain,  three  times  a  day,  producing  the 
characteristic  constitutional  effects  of  the  drug,  but  without  any 
effect  upon  the  voice.     In  one  case  of  a  young  lady  seventeen 


474   AFFECTIONS  OF  THE  LARYNX  AND  TRACHEA. 

years  of  age,  of  scrofulous  diathesis,  otherwise  healthy,  I  gave 
this  drug,  first  hypodermically,  then  internally  in  the  doses  men- 
tioned, withont  any  beneficial  results,  having  previously  failed 
with  faithful  resort  to  electricity,  applied  locally  and  externally. 
Finally,  when  the  patient  had  been  under  care  for  about  a  year, 
the  voice  returned  gradually  under  the  direct  influence  of  a  gal- 
vanic current  from  forty  small  Smee  cells,  applied  externally, 
with  interruptions  of  about  three  hundred  in  the  minute. 

Should  the  aphonia  arise  from  any  of  the  causes  narrated 
on  p.  469,  the  appropriate  constitutional  treatment  for  that 
condition  should  be  instituted,  in  addition  to  whatever  local 
measures  may  be  employed  for  the  restoration  of  the  voice. 

Dr.  Henry  K.  'Oliver,'  of  Boston,  has  called  attention  to-  a 
method  of  treating  aphonia  from  paralysis  of  intrinsic  muscles 
of  the  larynx  by  external  manipulation  of  the  organ,  with  re- 
storation of  voice  at  a  single  sitting. 

I  am  inclined  to  think  that  these  cases  belong  to  that  class  so 
often  cured  by  the  mere  introduction  of  the  mirror,  or  the  re- 
course to  other  indifferent  methods.  The  manipulation  consists 
essentially  in  compressing  the  wings  of  the  thyroid  cartilage,  in 
their  posterior  and  upper  part,  between  the  thumb  and  fore- 
finger. It  would  require  considerable  pressure  of  the  wings  of 
the  cartilage  to  traverse  the  space  of  the  pyramidal  sinuses  so 
as  to  approximate  a  pair  of  arytenoid  cartilages  — such  an 
amount  of  force  as  might  produce  fracture  in  an  unfortunate 
subject ;  while  the  moderate  degree  of  approximation  produced 
seems  insuflicient  in  itself  to  account  for  the  result,  without  in- 
voking the  influence  of  emotion,  or  muscular  resistance  on  the 
part  of  the  laryngeal  organ.  However,  in  absence  of  any  per- 
sonal experience,  it  is  unbecoming  to  pass  judgment.  In  two 
or  three  instances  in  which  electricity  restored  the  voice,  and  in 
one  in  which  it  was  restored  by  the  mere  introduction  of  the 
mirror,  this  method  was  tried  by  the  author  in  the  first  place,  a 
moderate  degree  of  force  only  being  employed;  but  without  any 
success;  and  he  has  not  cared  to  pursue  the  subject  any  farther. 
Accidental  choking  has  sometimes  cured  aphonia. 

'  Am.  Jour.  Med.  Sci,  April,  1870,  p.  305. 


LAETNGISMUS    STEIDULUS.  .  475 


LARYNGISMUS    STEIDULUS. 

■  This  is  tlie  name  given  to  a  peculiar  affection,  the  main  symp- 
tom of  which  is  a  spasmodic  contraction  of  the  glottis,  prevent- 
ing the  free  inspiration  of  air ;  the  attempt  at  inspiration  being 
usually  accompanied  by  a  peculiar  vocal  crowing  sound,  to  which 
the  name  stridulation  has  been  applied,  from  its  supposed  re- 
semblance to  the  stridulation  of  insects.  The  seriousness  of 
the  affection  consists  in  the  danger  of  suffocation  during  the 
continuance  of  the  spasm.  I  am  inclined  to  believe  that  the 
term  suffocative  laryngismus  wov^idi  ^enotQ  the  peculiar  charac- 
ter of  the  affection  better  than  any  other  which  has  been  pro- 
posed. 

It  is  purely  a  nervous  affection,  unaccompanied  by  any  in- 
flammation of  the  larynx,  and  should  not  have  received  the 
name  of  spasmodic  croup.  It  is  occasionally  encountered  in 
adults,  but  is  particularly  a  disease  of  childhood,  occurring  usu- 
ally during  the  period  of  the  first  dentition. 

The  pathology  of  this  affection  was  long  misunderstood,  until 
it  was  shown  by  Dr.  Marshall  Hall  to  be  usually  due  to  the 
reflex  action  excited  in  the  motor  system  of  nerves  by  the  irrita- 
tion of  the  trifacial  in  dentition,  the  pneumogastric  in  nutrition, 
or  the  spinal  nerves  in  disorders  of  the  intestines.  It  occurs 
frequently  in  children  of  the  scrofulous  diathesis,  especially  those 
who  are  the  subjects  of  rickets;  and  caries  of  the  cervical  verte- 
brae has  in  some  instances  been  discovered  after  death.  The  pres- 
sure of  an  enlarged  thymus  gland,  of  an  abscess,  or  of  an  en- 
larged bronchial  gland  upon  some  part  of  the  course  of  the  pneu- 
mogastric or  of  the  spinal  accessory  nerve  is  also,  at  times,  the 
cause  of  this  affection. 

The  affection  shows  itself  suddenly,  usually  during  sleep ;  the 
child  waking  in  fright  with  excessive  dyspnoea,  accompanied 
by  the  peculiar  phonal  inspiration  produced  by  the  passage  of 
the  inspiratory  current  through  a  spasmodically  contracted  glot- 
tis, the  lips  of  which  are  set  in  vibration  as  the  air  is  forced 
past  them.  All  the  symptoms  of  impending  suffocation  are 
present  during  the  paroxysm,  and  death  may  take  place  in  con- 
sequence;  but  usually,  just  as  asphyxia  seems  immineut,  the 


476       AFFECTIOlSrS    OF   THE    LAEYNX    AND    TEACKEA. 

spasm  relaxes,  the  air  rushes  into  the  windpipe  mth  the  char^- 
teristic  stridor,  and  the  paroxysm  is  over  for  the  time,  the  entire 
phenomena  occupying  but  a  few  moments.  Sometimes  but  a 
single  paroxysm  occurs;  but  more  usually  others  follow  at  inter- 
vals of  a  iew  days  or  a  few  hours,  and  often  with  incj-easing 
frequency.  Sometimes  the  first  paroxysm  is  the  most  serious 
one  of  tlie  series,  but  not  infrequently  it  is  less  serious  than  those 
that  follow.  Sometimes  the  paroxysms  are  accompanied  with 
spasmodic  contractions  of  the  extremities,  and  occasionally  they 
are  followed  by  general  convulsions.  Sometimes  sudden  fright, 
or  sudden  excitement  in  play,  such  as  is  produced  by  tossing 
the  child  into  the  air,  excites  the  first  paroxysm  of  the  affection. 

The  treatment  during  the  paroxysm  is  directed  towards  re- 
laxing spasm  and  thus  warding  off  asphyxia ;  being  such  as  the 
dashing  of  cold  water  upon  the  child's  face,  and  other  exposed 
parts  of  its  body ;  exposing  the  surface  to  a  current  of  cool  air ; 
slapping  the  breast,  back,  etc. ;  the  patient  being  placed  in  a 
warm  hip-bath,  if  the  conveniences  for  so  doing  ai-e  at  hand. 
This  is  usually  all  that  can  be  done  at  the  first  paroxysm.  For 
nse  in  subsequent  paroxysms,  warm  water  should  be  at  hand 
for  ]3urposes  of  the  bath,  or  for  the  administration  of  an  enema ; 
or  an  anaesthetic,  for  use  by  inhalation. 

After  the  paroxysm  has  subsided,  efforts  must  be  made  to 
overcome  the  source  of  irritation,  which  may  reside  in  the 
teeth,  in  the  stomach,  in  the  intestines,  or  in  the  brain.  In  ad- 
dition to  this,  antispasmodic  remedies  should  be  employed  ex- 
ternally and  internally ;  with  the  cautious  resort  to  narcotics,  if 
not  contra-indicated. 

If  the  child  is  not  strong,  as  is  frequently  the  case,  the  use  of 
vegetable  or  mineral  tonics  is  indicated. 

The  gums  should  be  attended  to,  the  bowels  kept  relaxed, 
and  great  care  be  paid  to  diet,  proper  clothing,  and  equable 
temperature. 

The  al)sence  of  fever,  cough,  and  alteration  of  the  voice, 
or  aphonia,  in  the  latter  stages,  distinguishes  this  affection  from 
croup,  with  which  it  is  sometimes  confounded, 

Laryngisuius  stridulus  likewise  occurs  in  the  adult,  some- 
times in  connection  with  a  j)aralytic  conditi(jn  of  the  posterior 


LAEYNGISMIIS    STRIDULIJS.  477 

crrco-arjtenoid  muscles,  as  mentioned  elsewhere,  page  469. 
Under  these  circnmstances  the  rigid  approximation  of  the  vocal 
cords  can  be  observed  in  the  laryngoscopic  image.  The  cause 
in  the  adult  may  be  reflex  action  from  disease  of  the  alimen- 
tary canal  or  other  portions  of  the  body  ;  or  it  may  be  of  cere- 
bral origin,  or  be  due  to  pressure  upon  the  nervous  trunks  ;  or 
it  may  be  one  of  the  manifestations  of  hysteria.  The  condition 
is  sometimes  attendant  upon  phthisis,  as  has  occurred  in  two  in- 
stances under  the  author's  care.  AYliere  the  paralytic  condition 
referred  to  exists,  any  slight  exertion,  or  even  mental  emotion, 
will  give  rise  to  the  spasmodic  action  of  the  glottis.  Rest,  then, 
physical  and  mental,  is  an  important  element  in  the  treatment 
of  the  affection.  Systemic  remedies  suited  to  the  peculiar  con- 
dition of  the  organs  of  digestion  and  secretion  are  required, 
together  with  the  use  of  antispasmodics,  and  of  relaxing  inha- 
lations. Topical  treatment  of  the  larynx  is  inapplicable,  in 
consequence  of  the  danger  of  exciting  spasm  of  the  glottis.  If 
the  affection  is  persistent,  and  especially  if  laryngoscopic  in- 
spection reveals  the  paralytic  conditions  of  the  muscles  which 
widen  the  glottis,  tracheotomy  is  indicated  as  a  means  of  avoid- 
ing the  liability  to  suffocation ;  and  it  becomes  imperatively 
demanded  if  there  are  any  evidences  of  inflammatory  action, 
inasmuch  as  a  moderate  swelling,  which  would  be  of  no  mo- 
ment under  ordinary  circumstances,  would  here  render  respi- 
ration impossible. 

If  the  conditio]!  should  continue  after  the  performance  of 
tracheotomy,  the  local  application  of  the  electric  current  to  the 
affected  muscles  w^ould  hold  out  reasonable  prospects  of  cure. 
Should  this  fail,  the  opening  in  the  trachea  would  have  to  be  kept 
patulous  until  the  condition  subsided  spontaneously,  or  through 
the  influence  of  a  genei-al  tonic  treatment. 

A  condition  somewhat  similar  to  that  just  narrated  may  arise 
from  spasm  of  the  trachea,  and  would  be  distinguished  from 
spasm  of  the  larynx  by  the  use  of  the  laryngoscope  as  a  means 
of  diagnosis.  This  is  inferred  from  the  following  note  quoted 
from  Porter.' 

^  Observations  on  the  Surgical  Pathology  of  the  Larynx  and  Trachea,  by 
William  Henry  Porter,  A.M.     London,  1837,  p.  18,  note. 


478       AFFECTIONS    OF    THE    LAEYJN^X    AND    TEACHEA. 

"  In  opposition  to  the  idea  of  spasm  only  occnrring  in  situa- 
tions that  admit  of  being  acted  on  by  muscular  contraction, 
there  is  a  case  related  in  the  11th  vol.  of  the  JEdin.  Med.  and 
Surg.  Journal,  the  dissection  of  which  showed  a  contraction  of 
the  trachea  to  more  than  two-thirds  of  its  diameter,  and  one 
inch  and  a  half  in  length,  situated  midway  between  the  larynx 
and  the  bifurcation  of  the  trachea.  The  contraction  relaxed 
gradually  after  the  tube  was  slit,  so  that,  the  day  following,  the 
part  did  not  appear  contracted,  or  in  a  state  of  disease  of  any 
kind." 

SPASMODIC   COUGH. 

A  very  curious  nervous  affection  of  the  larynx  now  and  then  en- 
countered is  that  of  a  peculiar  spasmodic  cough,  occurring  with- 
out the  existence  of  any  appreciable  lesion.  It  is  most  frequent- 
ly met  with  in  females,  and  is  usually  attributable  to  hysteria. 
I  have  met  cases  of  this  kind  in  married  as  well  as  in  unmarried 
women,  and  in  males  as  well  as  in  females.  The  cough  usually 
has  some  characteristic  tone  about  it,  such  as  that  of  the  cry  of 
one  of  the  lower  animals ;  the  yelping  as  of  a  little  cur  being 
the  sound  most  frequently  met  with.  Paroxysms  of  cough  will 
come  on  more  or  less  frequently  at  irregular  intervals  of  about 
five  or  ten  minutes,  half  an  hour  or  longer,  and  continue  for 
two,  three,  five,  or  more  minutes  at  a  time,  the  characteristic 
sound  of  the  cough  being  repeated  fifty  or  sixty  times  a  minute. 
In  one  remarkable  case  of  this  kind  under  the  author's  care,  a 
few  years  ago,  the  sound  of  the  cougli  might  be  represented  by 
the  syllables  "  ha,  hich,"  the  latter  syllable  having  the  Greek 
or  Teutonic  sound,  and  being  given  at  a  pitch  a  fourth  higher 
than  that  of  the  first  one.  The  subject  of  this  affection  was  the 
daughter  of  a  clergyman.  In  another  subject,  also  the  daughter 
of  a  clergyman,  the  sound  was  so  much  like  that  of  a  little  poodle, 
that  patients  in  the  reception-room  during  the  time  of  her  visit 
would  ask  eacli  other,  "  Wli}^,  that  lady  hadn't  sense  enough  to 
leave  her  dog  in  her  carriage."  This  chai-acter  of  cough  I  have 
met  with  in  other  cases  also.  Some  twenty  years  ago,  a  lady's 
boarding-school  in  Philadelphia  was  broken  up  in  consequence 
of  an  hysterical  spasmodic  cough  of  this  kind  breaking  out 


SPASMODIC    COUGH.  479 

among  the  scholars,  a  nnmber  of  whom  became  affected  with 
it  one  after  the  other.  The  people  in  the  neighborhood,  hearing 
of  it,  were  wont  to  collect  in  front  of  the  school-honse  to  hear  the 
girls  bark ;  and  this  only  made  matters  worse,  so  that  finally 
the  school  had  to  be  temporarily  dismissed,  and  the  girls  sent 
home  to  their  various  residences. 

I  have  had  under  my  care  three  cases  of  spasmodic  cough 
occurring  in  three  brothers  over  forty  years  of  age,  a  fourth  and 
older  brother  being  similarly  affected ;  the  cough  having  contin- 
ued in  each  case  from  fifteen  to  twenty-five  or  more  years.  The 
father  of  these  four  brothers  was  subject  to  similar  cough  from 
his  boyhood  until  he  had  become  over  seventy  years  of  age,  since 
which  time,  a  period  of  more  than  ten  years,  he  has  not  had  this 
cough.  The  sisters  of  these  gentlemen  have  never  been  affected 
with  the  cough.  The  father  and  three  of  the  sons  are  regular 
physicians  in  good  standing.  The  three  cases  referred  to  I  ex- 
amined laryngoscopically.  The  larynx  was  very  much  congested 
in  each  case,  but  I  could  see  no  cause  for  the  trouble,  unless  it 
existed  in  the  possession  of  a  very  large  epiglottis.  The  gentle- 
man having  the  largest  epiglottis  informed  me  that  he  was  subject 
to  suffocative  spasms  at  the  dinner-table,  in  one  or  two  of  which 
he  has  become  unconscious,  but  has  been  brought  to  by  his  wife, 
who  places  her  fingers  back  in  his  throat.  Two  of  the  brothers 
have  had  several  similar  spells  also,  though  they  recovered  with- 
out the  interference  of  a  second  person.  I  feel-  inclined  to  the 
opinion  that  the  epiglottis  of  these  gentlemen  sometimes  becomes 
impacted  into  the  larynx  in  deglutition,  thus  producing  the 
spasm  of  suffocation ;  a  condition  which  I  have  known  to  occur 
repeatedly  in  a  young  child  who  was  subject  to  suffocative  par- 
oxysms, in  whom  I  detected  a  large  epiglottis  as  the  cause  of  the 
j)aroxysms,  and  whose  mother  I  taught  the  method  of  relief  by 
running  her  finger  down  beneath  the  epiglottis  and  pulling  it 
up.  This  little  fellow  was  also  subject  to  spasmodic  cough.  A 
similar  cause  excites  spasmodic  cough  every  night  in  a  little 
child  under  treatment  at  the  moment  of  writing. 

In  another  case  of  a  lady  of  Philadelphia  who  had  been  married 
for  twenty-eight  years,  and  who  had  been  a  subject  of  spasmo- 
dic cough  for  more  than  twenty  years,  I  found  an  epiglottis  quite 


480       AFFECTIOlSrS    OF   THE    LARYNX   AND    TEACHEA    "^ 

deeply  indented  in  the  centre  of  its  free  edge,  its  lateral  portions 
projecting  so  much  beyond  the  de23ressed  portion  as  to  give 
it  somewhat  the  appearance  of  a  fissure.  The  laryngeal  face  of 
the  epiglottis  was  red  and  very  velvety  in  appearance. 

The  treatment  of  cases  of  this  kind  is  very  perj)lexing.  Anti- 
spasmodic remedies  avail  at  one  time  and  are  useless  at  others. 
The  general  health,  when  impaired,  and  this  is  frequently  the 
case,  must  be  attended  to ;  and  in  females,  any  irregularity  of 
nienstruation,  or  other  uterine  difficulty,  is  to  be  corrected. 
Locally,  I  have  found  anodyne  inhalations  to  moderate  the  in- 
tensity and  frequency  of  the  cough.  This  may  also  be  accom- 
plished at  times  by  the  internal  use  of  belladonna,  bromide  of 
potassium,  arsenite  of  potassa,  or  other  remedies  addressed  to  the 
nervous  system.  Sometimes,  the  use  of  strychnia,  internally,  con- 
trols the  cough.  In  one  of  the  cases  of  the  brothers  just  men- 
tioned, I  found  good  results  follow  the  local  application  of  tinc- 
ture of  aconite  root  to  the  epiglottis,  followed  immediately  by  a 
saturated  solution  of  tannin  in  glycerine.  This  relieved  the  cough 
from  the  first,  and  for  some  considerable  time  the  gentleman  has 
had  a  great  deal  of  reduction  in  the  frequency  and  intensity  of  the 
paroxysm ;  and  at  a  very  recent  interview  he  stated  that  his  cough 
had  lost  its  peculiar  shrill,  unj^leasant  sound,  and  seems  more 
like  the  chronic  cough  frequently  met  with  in  elderly  people. 

In  one  or  two  instances  I  found  good  results  from  the  local 
employment  of  electricity  ;  but  I  am  not  prepared  to  deny  that 
the  emotional  influence  of  the  manipulations  was  not  without  a 
calming  effect.  In  these  applications  I  employed  the  positive 
pole  of  an  aj)paratns  of  induction  within  the  larynx,  and  the 
negative  pole  by  large  electrodes  to  the  naked  feet.  After  em- 
ploying it  in  this  manner  for  a  few  moments,  the  positive  pole 
was  shifted  to  the  exterior  of  the  larynx,  the  operator's  hand 
being  employed  as  electrode.  During  the  applications  of  the 
current  the  cough  ceased,  and  would  often  remain  controlled 
for  hours  at  a  time,  occurring  less  and  less  frequently,  and  in 
shorter  paroxysms,  with  pei'haps  but  one  or  two  characteristic 
barks  at  a  time  instead  of  fifty  to  sixty  in  rapid  succession,  and 
so  on,  gradually  diminishing  in  frequency  and  intensity,  until 
the  attacks  ceased  altogether. 


SPASMODIC    COUGH.  48l 

At  other  times,  I  have  resorted  effectually  to  the  continuous 
galyanic  current  from  ten  to  fifteen  or  twenty  elements,  an 
elongated  electrode  connected  with  the  positive  pole  being  placed 
over  the  region  of  the  sympathetic  nerve  in  the  neck,  on  each 
side  alternately,  a  few  minutes  at  a  time,  and  the  other  electrode 
being  held  in  the  hand  of  the  same  side.  In  one  instance,  oc- 
curring in  a  lad  of  eleven  years  of  age,  the  son  of  a  medical 
gentleman,  a  single  application  of  this  kind  seems  to  have  con- 
trolled the  spasmodic  cough  at  once  and  permanently,  though  it 
had  existed  for  several  months,  and  was  very  severe  in  cha- 
racter. Applications  of  this  kind  must  be  made  with  great  care, 
and  be  discontinued  immediately  upon  the  occurrence  of  any 
unpleasant  sensations  in  the  part,  in  the  chest,  or  in  the  head. 
Each  application  should  continue  for  thirty  seconds  to  three  or 
four  minutes  only,  according  to  the  susceptibilities  and  toler- 
ance of  the  patient. 

A  spasmodic  cough,  of  less  intensity,  sometimes  occurs  in  affec- 
tions of  the  ear,  the  influence  being  conveyed,  probably,  through 
the  chorda  tympani  nerve.  Consequently  in  cases  of  obstinate 
cough,  without  sufficient  cause  for  it  appearing  in  the  throat, 
the  condition  of  the  organs  of  audition  should  be  carefully  ex- 
amined into.  Inasmuch  as  affections  of  the  epiglottis,  such  as 
oedema,  ulceration,  etc.,  are  sometimes  accompanied  by  severe 
pain  in  the  ears,  pain  to  which  the  local  suffering  at  the  seat  of 
disease  is  as  nothing  in  comparison,  it  is  likely  that  a  reverse 
influence  produces  an  irritability  of  the  epiglottis  or  of  the  glottis 
itself,  in  cases  of  affections  of  the  ear  or  of  the  Eustachian  tube, 
to  the  pharyngeal  portion  of  which  the  lajrynx  is  in  direct  com- 
munication by  one  of  the  divisions  of  the  pharyngo-palatine 
muscle.  The  cause  of  the  ear-cough  being  recognized,  the 
treatment  will  of  course  be  directed  to  that  cause. 

The  larpigoscopic  appearance  of  the  glottis  in  the  production 
of  spasmodic  cough  is  very  peculiar.  The  cords  are  seen  to 
come  together  as  though  driven  with  great  force  from  the  exte- 
rior, and  then  suddenly  to  separate  as  the  pecuhar  sound  of  the 
"cough  is  made.     I  have  thus  watched  the  action  of  the  parts 

over  and  over  again  during  the  entire  paroxysm  of  a  barldng 
31 


482        AFFECTIOlSrS    OF   THE    LAEYNX    AISTD    TRACHEA. 

congh,  witiiont  in  the  slightest  way  embarrassing  the  patient,  or 
the  congh  either.  Occasionally  I  have  found  that  a  forced 
expiration  or  a  forced  inspiration  would  break  the  spasm  for  a 
moment ;  and  under  these  circumstances  the  patient  is  enabled 
to  control  the  paroxysm,  a  matter  of  a  great  deal  of  moment  as 
permitting  re-entrance  into  society,  itself  beneficial  therapeu- 
tically as  a  mental  or  emotional  tonic.  There  is  little  evidence 
of  local  trouble  in  the  larynx,  but  usually  an  intense  injection 
of  the  mucous  membrane  covering  the  cartilaginous  corpuscles 
of  Santorini,  and  very  often  a  similar  condition  on  the  laryngeal 
face  of  the  epiglottis,  and  sometimes,  again,  congestion  of  the 
entire  larynx ;  these  appearances  being  the  result  of  the  con- 
stant cough,  in  all  joi'obability,  and  not  its  cause. 

WHOOPING-COUGH. 

Whooping-cough,  technically  known  as  pertussis,  is  a  very 
curious  aifection  of  the  upper  air-passage,  the  patliology  of 
which  is  not  well  understood,  despite  the  great  frequency  of  its 
occurrence.  That  it  is  a  specific,  contagious  affection,  attacking 
the  individual  but  once,  as  a  rule,  all  observers  admit.  It  has 
been  considered  a  specific  catarrhal  bronchitis  by  some,  a  spe- 
cific fever  by  others,  and  by  others,  again,  as  essentially  a  special 
neurosis,  or  spasmodic  affection  of  the  air-passages.  The  charac- 
teristic symjDtoms  of  the  disease  are  catarrhal  infiammation  of 
the  upper  air-passages,  fever  to  a  greater  degree  than  can  be 
accounted  for  by  the  intensity  of  the  inflammation,  and  a  cha- 
racteristic expiratory  spasm  of  the  glottis  attended  with  a  pecu- 
liar cough. 

For  a  long  time  the  oj^inion  has  been  gaining  ground  that  this 
disease  is  due  to  the  contact  of  some  special  organism  which,  in 
exciting  the  disease,  exhausts  the  excitability  of  the  system  to  the 
influence  of  the  poison.  It  is  hard  to  understand  the  immunity 
from  subsequent  attacks  in  this  and  other  affections  attributed 
to  such  causes.  It  is  hard  to  believe  that  there  are  a  number  of 
certain  elements  in  the  blood  capable  of  being  renewed,  in  the 
cycle  of  waste  and  repair,  only  until  they  have  been  used  up  by 
this,  that,  and  the  other  contagious  disease.  Yet,  we  cannot 
well  account  for  immunity  to  subsequent  exposure  on  any  other 


'\YHOOPING-COIJGH.  483 

ground.  Linnaeus  considered  the  external  organism  of  whoop- 
ing congh  an  animalcnlar  insect ;  so  too,  in  part,  did  Kosen, 
thongh,  with  Bohme  and  others,  he  also  considered  that  it  might 
be  of  miasmatic  origin.  Recent  observers  have  developed  this 
theory  still  fnrther,  and  some  of  them  claim  to  have  detected  the 
offending  bodies.  M.  Poulet  took  advantage  of  an  epidemic  in 
his  neighborhood  to  examine  the  breath  of  many  children  af- 
fected with  the  disease,  and  stated  in  a  commnnication  to  the 
Parisian  Academy  of  Science  ^  that,  on  microscopic  examin- 
ation of  the  vapor  of  the  breath,  collected  by  him,  he  fonnd  a 
world  of  minute  infusoria,  which  were  in  all  cases  identical. 
The  most  numerous,  as  well  as  the  most  minute,  belonged  to  a 
species  known  as  Monas  termo,  or  as  Bacterium  termo ;  while 
he  also  found,  in  smaller  numbers,  another  species,  the  Monas 
punctum  of  Mliller,  Bodo  punctum  of  Ehrenberg,  classed 
among  the  bacteria.  Letzerich^  claims  to  have  discovered  the 
"  piltz  "  or  fungus  of  whooping-cough.  He  states  that,  in  the 
catarrhal  stage  of  the  disease,  the  sputa  contain  small  roundish 
or  elliptical  reddish-brown  spores  which  subsequently  develop 
filaments  rajDidly.  In  the  second  stage  of  the  disease  these  fila- 
ments are  found  matted  together,  and  bearing  small  round 
spores  at  their  extremity.  These  germs,  unlike  the  germs  found 
in  diphtheria,  do  not  penetrate  the  epithelial  cells  of  the  mucous 
membrane,  but  the  mucus  corpuscles  are  often  filled  with  them. 

Whooping-cough  is  eminently  an  affection  of  childhood,  but 
sometimes  appears  in  the  adult. 

The  initial  symptoms  are  essentially  those  of  coryza,  with  the 
addition,  in  some  instances,  of  the  symptoms  of  bronchitis. 
The  cough  soon  becomes  more  violent  than  that  of  oj-dinary 
coryza,  and  its  paroxysms  more  persistent ;  and  in  the  course  of 
two  or  three  days  in  some  cases,  though  not  until  two  or  three 
weeks  in  others,  the  cough  becomes  distinctly  paroxysmal.  It 
is  then  that  the  pecidiar  whoop  is  produced  which  has  given  its 
name  to  the  affection.  The  cough  occurs  in  paroxysms  of  a 
number  of  successive  sonorous  expiratory  efforts,  apparently 
without  any  attempt  at  inspiration,  continuing  often  until  a 

'  (Gaz.  Hebd.  Aug.  16,  1867)  A7n.  Jour.  Med.  Sd.  April,  1868.     p.  531. 
""  ( Virchow's  ArcJdv.  March)  The  Med.  Times,  Jan.  2,  1871.     p.  125, 


484       AFFECTIOiTS    OF    THE    LAET]S"X   AjS'D    TEACHEA. 

veritable  aspli}^ia  is  impending,  tlie  number  of  coughs  vaiyirg 
from  six  to  twenty  or  more  at  each  paroxysm.  Finally  a  deep 
and  labored  inspiration  is  drawn  into  the  exhausted  lungs,  the 
air  passing  a  spasmodically  contracted  glottis  and  thus  giving  rise 
to  that  peculiar  stridulous  sound  which  is  denominated  the  whoop. 
Then  follows  another  succession  of  coughs,  succeeded  by  the 
shrill  whooping  inspiration ;  and  this  is  repeated  again  and  again, 
the  entire  series  constituting  a  paroxysm  which  may  last  from 
half  a  minute  to  fifteen  minutes  or  more.  During  the  paroxysm 
there  is  dyspnoea,  impeded  circulation  of  the  blood  and  its  con- 
sequences, flushed  and  livid  face,  distention  of  the  cervical  and 
temporal  veins,  protrusion  of  the  eyeballs,  suffusion  of  tears, 
etc. ;  these  symptoms  being  proportionate  in  severity  to  the 
severity  of  the  paroxysm.  Sometimes  the  paroxysms  are  ex- 
ceedingly violent,  attended  with  hemorrhage  fi*om  the  nose  and 
mouth,  even  from  the  ears  and  fi-om  other  localities  ;  and  some- 
times there  occur  involuntary  passages  of  urine  and  faeces. 
Dilatation  or  rujjture  of  the  air-vesicles  sometimes  results  from 
the  violence  of  the  paroxysm,  giving  rise  to  emphysema.  The 
paroxysm  usually  terminates  with  an  expectoration  of  mucus, 
and  sometimes  with  vomiting  ;  the  relaxation  of  the  spasm,  in 
some  instances,  seeming  to  be  due  to  the  emesis  as  a  cause. 

The  paroxysms  recur  irregularly,  and  often  without  special 
exciting  cause.  They  are  often  brought  on  by  the  opening  of  a 
door,  by  emotion,  by  the  act  of  swallowing,  and  by  witnessing,  or 
merely  hearing  the  paroxysm  in  another,  etc.  There  may  be 
only  a  few  paroxysms  in  the  twenty-four  hours,  or  there  may  be 
many,  amounting,  in  some  instances,  to  as  many  as  a  hundred, 
it  is  said.  The  paroxysms  are  sometimes  more  fi-ecpient  at  night 
and  sometimes  more  frequent  in  the  day-time.  The  fi-equency 
and  violence  of  the  paroxysms  usually  increase  for  four  or  five 
weeks,  sometimes  not  so  long ;  then  there  seems  to  be  no  change 
for  a  few  days  or  for  two  or  three  weeks,  after  which  their  vio- 
lence and  fi'equence  decline.  The  average  duration  of  whoop- 
ing-cough is  perhaps  about  nine  weeks ; — and  w^aiting  nine  weeks 
often  constitutes  the  best  treatment.  Many  cases  terminate  soon- 
er, and  many  are  pr(;longed  longer ;  and  in  a  few  instances  the 
affection  has  been  asserted  to  have  continued  longer  than  a  year. 


WHOOPIXG-COUGH.  485 

Wliooping-congli  in  itself  is  not  dangerous  to  life,  but  maybe- 
come  so  in  consequence  of  the  complications  wliicli  arise  from 
the  state  of  constitution,  or  the  effects  of  the  paroxysm.  It  is  not 
infrequently^  associated  with  measles  in  the  same  individual. 

The  treatment  that  has  been  adopted  for  whooping-cougli  is 
very  yarious,  the  remedies  having  being  addressed  to  the  nervous 
system,  the  circulatory,  or  the  respiratory  system,  separately,  or 
in  connection.  Thus  assafoetida,  musk,  valerian,  belladonna, 
recently  bromide  of  potassium,  etc.,  form  integral  elements  of  the 
treatment.  Of  late  inhalations  have  been  freely  employed  in  the 
management  of  whooping-cough,  as  has  been  fully  treated  of  by 
the  author  elsewhere.^  Kemarkably  beneficial  effects  seem  to  at- 
tend the  employment  of  the  vapor  of  illuminating  gas  just  after 
its  subjection  to  the  purifying  process.  This  method  has  been 
employed  with  success  at  Amsterdam,  Calais,  Paris.  Yienna,  and 
other  places  ;  and  I  have  been  informed  by  some  of  my  pro- 
fessional fi'iends  that  it  has  been  tried  with  success  in  Phila- 
delphia. About  twelve  visits  to  the  gas-works  are  required,  the 
duration  of  each  visit  being  about  two  hours.  The  use  of  ben-  ^ 
zine  or  of  carbolic  acid  sprinkled  about  the  pillow,  or  placed  in 
shallow  vessels,  has  been  employed  as  a  home-substitute  for 
this  treatment.  The  use  of  sulphurous  vapors,  nitrous  vapors, 
turpentine  vapors,  and  the  sprays  of  various  solutions  have  also 
been  highly  spoken  of.  The  value  of  many  of  these  articles 
Avould  seem  to  depend  upon  their  anti-zymotic  influence.  Dr. 
Snow,  of  Providence,  P.  I.,  has  suggested^  the  use  of  the  carbo- 
late  of  lime  placed  in  saucers  about  the  room  in  which  the  child 
is  sleeping,  merely  sufficient  to  impregnate  the  apartment  with 
the  odor  from  it.  Binz^  extols  the  use  of  the  hydrochlorate  of 
quinia,  one  part  to  one  hundred.  Mr.  John  Grantliam  recom- 
mends* the  use  at  bedtime  of  the  vapor  of  ammonia,  evolved 
from  an  ounce  of  the  strong  solution  thrown  in  an  open  vessel  con- 
taining a  gallon  of  boiling  water  kept  hot  by  a  red-hot  half  brick. 

'  Inhalation;  its  Therapeutics  and  Practice.     Phil.  1867.  pp.  144,  216  etseq. 

2  The  Medical  Record,  Vol.  3,  p.  513. 

=*  Practitioner,  Nov.  1869,  p.  304. 

"Brit.  Med.  Jbiw.,  Sept.  16,  1871,  p.  323. 


486      AFrECTio]^s  of  the  laeynx  and  trachea. 

The  local  use  of  nitrate  of  silver  has  been  highly  recom- 
mended in  whooj)ing-congh  by  Drs.  Eben  Watson/  Pearce, 
Gibb,'  and  others.  It  is  employed  in  the  early  or  catarrhal 
stage,  and,  it  is  claimed,  with  an  abortive,  or  at  least  greatly 
shortening  result.  Dr.  Eohn,  of  Hanau,  v^as  led'  to  the  em- 
ployment of  inhalations  of  this  substance  in  solution,  from  the 
laiyngoscopic  appearances  exhibited  by  adults  and  children 
while  suffering  from  the  complaint.  He  found  the  upper  por- 
tion of  the  trachea  and  the  lower  portion  of  the  larynx  markedly 
congested,  causing  the  vocal  cords  to  appear  whiter  than  they 
really  were  from  the  contrast ;  and  he  states  that  adults  and  larger 
children  complained  of  severe  irritation  of  a  peculiar  character 
at  this  point,  just  before  the  onset  of  the  spasm  of  coughing. 

WOUNDS    or    THE  LAETis'X  AND    TEACUEA. 

Wounds  of  the  larynx  and  trachea  are  met  with,  occasionally 
as  the  result  of  accident,  sometimes  of  attempts  at  murder,  but 
most  frequently  as  the  result  of  suicidal  mutilation.  Througli 
ignorance  of  the  anatomy  of  the  parts,  coupled  with  the  notion 
that  a  wound  in  the  windpipe  must  of  necessity  be  fatal,  these 
attempts  fail  in  producing  death  oftener  than  they  succeed. 
The  reason  that  so  many  of  these  suicidal  attempts  are  unsuc- 
cessful is,  that  the  subject  bends  his  head  backwards,  a  move- 
ment which  has  a  tendency  to  press  the  large  vessels  back  out 
of  the  way  of  the  knife.  A  knife  of  some  kind,  or  some  sub- 
stitute for  it,  as  the  handle  of  a  spoon  sharpened  upon  a  stone, 
is  usually  employed  for  suicidal  purposes ;  and  the  devices  re- 
sorted to  by  the  insane,  and  by  individuals  incarcerated  for 
penal  offence,  are  sometimes  very  ingenious.  When  death  oc- 
curs under  these  circumstances  it  is  usually  very  rapid,  result- 
ing from  the  hemorrhage  from  the  great  vessels  of  the  neck, 
and  not  from  the  injury  to  the  air-passage.  The  larynx  is  said 
to  be  the  usual  seat  of  this  wound,  but  the  trachea  seems  to  be 

^  {Asaociution  Med.  Jour..,  August  16,  1853)  Am.  Jour.  Med.  Sci,  Oct.  1853, 
p.  491. 

-  On  Diseases  of  the  Throat  and  Windpipe.     2d  edit.,  p.  291. 

'  Ween.  Med.  Woch.  xvi.  1860,  pp.  52,  53  ;  Schmidt's  Jahrb.,  Nov.  1866,  p.  57. 
Cohen;  On  Inhalation,  etc.,  p.  145. 


FEACTUEE    OF    THE    LAETNX.  487 

severed  as  ofteii ;  for  Sabatier's  list  ^  gives  the  larynx  as  the  seat 
of  ii^jury  in  twenty-three  instances,  and  the  trachea  in  twenty- 
two.  The  seat  of  injury  concerned  the  hyo-thyroid  membrane 
in  twelve  cases,  the  thyroid  cartilage  in  ten,  the  crico-thyroid 
membrane  in  thirteen,  the  crico-tracheal  membrane  in  one,  and 
the  trachea  in  twenty-two  cases.  Wounds  of  the  epiglottis, 
which  sometimes  occnr,  are  not  mentioned  in  the  list  referred  to. 

In  the  treatment  of  cases  of  this  kind  it  is  recommended  that 
the  surgeon  be  not  too  assiduons  in  closing  the  external  wound, 
as  there  is  danger  of  hemorrhage  when  reaction  comes  on,  on 
account  of  the  extent  of  tissue  usually  severed.  It  is  best  to 
await  reaction,  and,  if  hemorrhage  occurs,  to  ligate  the  bleed- 
ing vessels,  or  arrest  the  bleeding  by  styptics,  as  the  case  may 
recjnire,  the  parts  being  brought  togethei*  lightly  by  adhesive 
strips,  and  not  closed  by  suture  nntil  all  danger  of  this  kind  is 
at  an  end.  During  the  treatment  the  head  should  be  brought 
down  npon  the  neck  by  appropriate  bandages,  so  as  to  secure 
apposition  of  the  transverse  w^ound.  If  symptoms  of  snffoca- 
tion  occur,  the  trachea  must  be  opened. 

During  the  healing  of  these  wounds,  contraction  is  very  apt  to 
occur,  necessitating  the  permanent  use  of  the  tracheotomy  tube. 
These  constrictions  have  been  overcome  in  a  few  instances  by 
Prof.  Liston.and  others;  the  method  employed  being  that  of 
gradual  dilatation.  In  one  instance  of  this  kind  I  was  enabled 
to  relieve  the  patient  from  the  necessity  of  wearing  a  tube, 
dilatation  being  produced  in  the  contracted  glottis  (the  wound 
having  been  directly  below  the  vocal  cords)  by  the  frequent 
passage  of  large  perforated  catheters  through  the  wound  up  into 
the  mouth,  and  the  seesawing  of  these  instruments,  up  and 
down,  b}^  means  of  the  two  hands. 

FEACTUKES    OF    THE    LARYNX  AISHD    TEACHEA. 

Fracture  of  the  Larynx.  —  Fractures  of  the  larynx  occa- 
sionally take  place  as  the  result  of  mechanical  injury,  sometimes 
in  connection  with  simultaneous  fracture  of  the  hyoid  bone,  but 
oftener  without  this  complication. 

^  Hourteloup  :  Plaies  du  larynx,  de  la  tracliee  et  de  Toesophage.  Paris, 
1869,  p.  16.  .         ■ 


488       AFFECTIOIfS    OF    THE    LAEYNX   AISB    TEACHEA. 

Usually  only  the  tliji'oid  and  cricoid  cartilages  suffer  frac- 
ture. The  arytenoid  cartilages,  on  account  of  their  mobility 
upon  the  cricoid,  escape  fracture,  and  are  more  apt  to  suffer 
dislocation.  In  many  cases  both  thyroid  and  cricoid  cartilages 
are  broken ;  but  when  the  accident  is  confined  to  one  cartilage, 
it  is  the  thyroid  which  is  most  frequently  fractm-ed.  These 
fractures  are  sometimes  single,  and  sometimes  multiple. 

In  46  cases  of  fractures  of  the  larynx  and  trachea  collected 
by  Gurlt,^  16  cases  occurred  in  persons  from  nine  years  of  age 
to  thirty,  12  in  males  and  4  in  females ;  which  may  not  represent 
the  proper  proportion,  inasmuch  as  in  a  number  of  these  cases 
the  age  of  the  patient  is  not  mentioned  in  the  original  report. 
It  will  thus  be  seen  that  ossification  of  the  cartilages  is  not  as 
important  an  element  in  this  form  of  injury  as  it  is  usually  sup- 
posed to  be.  In  these  16  cases,  in  6  the  thp-oid  cartilage  alone 
was  affected,  in  2  the  "larynx"  without  designating  what  por- 
tion, in  1  the  cricoid  alone,  in  1  the  trachea  alone. 

The  most  frequent  cause  of  fracture  is  a  murderous  attem23t 
at  choking  with  the  hand,  whether  premeditated  or  performed 
during  the  excitement  of  a  scuffle.  A  blow  upon  the  anterior 
portion  of  the  throat  with  the  fist,  or  with  some  hard  substance, 
as  a  billet  of  wood,  is  also  a  source  of  fracture.  Sometimes 
the  cause  is  purely  accidental,  as  a  fall  in  which  the  neck  strikes 
upon  a  hard  substance.  Occasionally,  it  is  said,  it  is  j)roduced 
in  awkward  hanging.  The  work  of  Giirlt,  already  referred  to, 
in  which  more  cases  are  brought  together  than  in  any  other 
work  that  I  have  been  able  to  procure ;  as  well  as  the  cases  given 
by  Gibb,"  show  the  general  nature  of  the  accident,  its  course 
and  termination.  A  few  isolated  cases  are  given  here  and  there 
in  the  medical  journals;  but  their  results  do  not  vary  essential- 
ly from  those  summed  up  by  Giirlt,  Gibb,  Fredet,"  and  Hunt.* 

The  symptoms  attending  a  fracture  of  the  larynx,  varying  of 

1  Handbuch.  der  Lehre  von  den  Knochenbriiclien  :  Dr.  Giirlt.  Hamm,  1864. 
TheU  11.    Lief  1. 

^  On  Diseases  of  the  Tkroat  and  Windpipe. 

^  Quelques  considerations  sur  les  fractures  traumatiques  du  larynx.  Paris,  1868. 

*  Fractures  of  Larynx  and  Ruptures  of  Trachea.  Am.  Jour.  Med.  Sci.,  April, 
1866,  p.  378. 


FEACTUEE    OF   THE    LAEYISTX.  489 

course  with  the  nature  and  extent  of  the  lesion,  will  be  as  fol^ 
lows :  At  first  a  spasmodic  cough,  sometimes  preceded  by  spit- 
ting of  frothy  blood,  and  very  soon  severe  dyspnoea  with  all  its 
accompaniments  of  cyanosis,  coldness  of  skin,  smallness  of 
pulse,  frequent  and  labored  respiration,  with  large  mucous 
larnygeal  rales,  hoarseness  of  voice  or  even  aphonia ;  and  some- 
times an  inability  to  speak  at  all,  a  few  inarticulate  tones  being 
forced  out  in  the  attempt ;  more  or  less  painful  swallowing ; 
and  in  all  severe  cases  attended  with  rupture  of  the  mucous 
membrane,  there  will  ensue  an  emphysema  of  the  throat  and  neck 
extending  steadily  over  the  face,  the  cervical  vertebrae,  down  into 
the  mediastinum,  and  sometimes  over  the  entire  body.  This 
emphysema  is  said  to  be  more  apt  to  take  place  in  the  inter- 
muscular than  in  the  subcutaneous  connective  tissue.  Cases 
occur,  but  exceptionally,  in  which  the  symptoms  will  not  be  at 
all  of  a  serious  character ;  perhaps  merely  soreness  and  some 
hoarseness  of  voice.  Manipulation  of  the  parts,  however,  affords 
the  evidence  of  fracture,  but  it  is  likely,  in  these  instances,  that 
the  internal  mucous  membrane  has  not  suffered  laceration.  In 
severe  cases  there  will  be  more  or  less  deformity  from  over-rid- 
ing of  the  fragments.  Cartilaginous  crepitation  will  also  be 
elicited  on  moving  the  fragments  one  upon  the  other;  but  care 
must  be  taken  not  to  mistake  for  this  the  crepitation  which  can 
be  produced  in  the  normal  larynx  by  lateral  movements,  or  by 
slight  pressure  against  the  vertebrae. 

It  is  also  to  be  remembered,  in  this  connection,  that  the  upper 
horn  of  the  thyroid  cartilage  is  occasionally  found  disconnected 
from  the  body  of  the  cartilage,  and  enclosed  in  the  lateral 
thyro-hyoid  ligament.  Luschka'  found  this  condition  in  three 
instances;  the  anomaly  existing  on  the  left  side  only,  in  each 
case.  It  would  therefore  appear  that  this  process  is  a  sort  of 
epiphysis ;  and  the  anomaly  in  question  is  well  to  be  i-emem- 
bered,  as  it  might  be  mistaken  under  certain  circumstances  for 
a  fracture,  the  result  of  mechanical  injury. 

Severe  cases  of  fracture  of  the  larynx  often  terminate  fatally 
at  once,  or  within  a  short  period  after  the  receipt  of  the  injury. 

1  Vircliow's  ArcMv.    March  18,  1868,  p.  478. 


490       AFFECTIOJSrS    OF   THE    LARYjN'X    AND    TRACHEA. 

Should  the  patient  survive  the  immediate  injury,  aucl  symptoms 
of  dyspnoea  present  themselves,  an  opening  should  be  promptly 
made  into  the  air-passage  belovi^  the  seat  of  injur}^  without 
waiting  for  the  effects  of  antiphlogistic  treatment.  Even  in 
cases  that  do  not  present  any  great  severity  of  symptoms  at 
first,  an  operation  of  this  kind  may  become  necessary  on  account 
of  the  production  of  oedema.  The  patient  should  be  placed  at 
perfect  rest,  and  the  case  be  treated  on  general  principles. 

The  displaced  fragments  should  be  replaced  with  the  greatest 
care;  and  in  some  instances  the  performance  of  laryngotomy, 
which  can  add  but  little  to  the  danger  of  the  case,  will  afford 
a  better  means  of  reposing  the  fragments  by  means  of  probes 
or  catheters  placed  within  the  larynx  through  the  artificial 
opening.  The  fragments  should  be  merely  replaced,  without 
any  attempt  to  retain  them  in  position  by  suture,  inasmuch  as 
the  results  of  experience  teach  that  the  cartilage  is  very  in- 
tolerant of  the  presence  of  sutures,  which  soon  cut  their  way 
out,  if  the  symptoms  they  produce  do  not  render  their  removal 
necessary.  The  wounds  in  the  soft  parts  may  be  approximated 
by  adhesive  strips  and  sutures,  care  being  taken  to  leave  an 
opening  below  sufhcient  for  drainage,  keeping  it  patulous,  if 
need  be,  by  a  shred  of  lint,  inasmuch  as  these  wounds  heal  by 
suppuration,  and  rarely  by  first  intention. 

The  insertion  of  a  canule  in  the  artificial  opening  is  usually 
required ;  and  in  many  instances  its  permanent  use  cannot  be 
dispensed  with  even  after  recovery  from  an  operation.  Some- 
times a  fistule  remains  ;  and  this  can  be  covered  up  by  a 
plastic  operation  externally. 

A  very  instructive  case  is  here  quoted  from  the  monograj)h 
of  Fredet,'  illustrating  the  nature  of  the  injury,  and  mode  of 
treatment;  and  showing  the  necessity  that  exists  for  perform- 
ing laryngotomy  or  tracheotomy  after  accidents  of  this  kind: — 

"  Triple  fractttre  of  cricoid  cartilage  j)rodiiced  hy  comjyres- 
sion  between  the  fingers — sudden  death  ujyon  an  ahrii^^t  move- 
ment of  tlie  jjoiient.     April  5th,  1867,  in  a  quarrel,  the  Sieur 

'  Quelques  considerations  sur  les  fractures  traumatiques  du  larynx.  Paris, 
1868,  p  5. 


FRACTURE  OF  THE  LARYNX.  491 

L  .  .  . ,  aged  30  years,  was  seized  by  tlie  throat  by  one  of  bis 
adversaries,  a  strong  and  vigorous  man,  who,  after  having 
thrown  him  to  the  ground,  held  him  some  instants  in  this 
position,  with  his  hand  applied  to  the  anterior  portion  of  the 
neck.  Seeing  that  L  .  .  .  could  not  rise,  that  he  made  the 
attempt  to  speak  without  being  able  to  pronounce  a  word,  and 
that  his  face  was  congested,  the  spectators  of  the  struggle  con- 
veyed the  wounded  man  to  liis  residence,  situated  at  some  kilo- 
metres distant  from  the  place  of  combat.  April  6th,  Prof.  Dr. 
Gagnon  was  called  in  attendance,  and  observed  the  following 
phenomena  :  Extreme  dyspnoea  ;  cyanosis  of  face  ;  slight  ecchy- 
moses,  more  pronounced  on  the  right  side,  wpon  the  lateral 
portions  of  the  neck,  from  the  vicinity  of  the  internal  boi'der 
of  the  sterno-mastoid  to  its  middle  portion,  at  a  point  cori-es- 
ponding  to  the  inferior  portion  of  the  larynx ;  the  anterior  por- 
tion of  the  neck,  as  far  as  the  pre-sternal  region,  was  infiltrated 
with  air  in  its  sub-cutaneous  cellular  tissue ;  slight  pressure 
with  the  fingers  on  these  parts  produced  the  peculiar  crej)itation 
of  emphysema.  There  was  none  of  the  characteristic  crepitation 
produced  by  the  rubbing  together  of  the  fractured  fragments. 

"  The  repeated  application  of  leeches  was  ordered,  and  under 
the  influence  of  the  sanguineous  flow,  the  tumefaction  of  this 
region  had  almost  completely  disappeared,  respiration  was  less 
embarrassed  ;  and  the  j^atient,  who  had  been  unable  to  articu- 
late a  sound  since  the  accident,  commenced  to  make  himself 
understood  on  the  evening  of  April  Vth.  Some  hopes  were 
then  entertained  of  a  favorable  issue  to  his  injury,  and  the 
operation  of  tracheotomy,  which  had  been  contemplated,  was 
deferred,  when,  during  the  night,  the  ]3atient,  after  satisfying  a 
call  of  nature  and  remounting  his  bed,  died  suddenly. 

^'Autopsy,  April  10,  at  Hotel  Dieu  de  Clermont. — No  effu- 
sion of  blood  encountered  in  the  dissection  of  the  supra  and 
subhyoid  regions.  The  thyroid  body  was  normal,  but  the  thyro- 
hyoid muscle  of  the  right  side  was  infiltrated  with  blood.  The 
larynx  was  removed  by  a  double  section  ;  one  practised  at  the 
base  of  the  tongue,  and  the  other  comprising  a  portion  of  the 
trachea.  After  a  careful  dissection,  there  was  revealed  a  triple 
fracture  of  the  cricoid  cartilage.     The  first  and  most  consider- 


492        AFFECTIOIS^S    OF    THE    LAEYNX   AIS^D    TEACHEA. 

able  one  was  situated  behind  and  on  the  middle  portion  of  the 
cartilage ;  it  was  vertical,  with  edges  as  sharp  as  if  made  by  a 
cutting  instrument ;  it  occupied  the  entire  extent  of  the  car- 
tilage and  joined  the  section  made  with  the  scissors  at  the  pos- 
terior portion  of  the  trachea.  The  two  other  fractures  were 
situated  right  and  left,  in  front  of  and  upon  the  lateral  por- 
tions of  the  cartilage ;  they  were  oblique  from  above  down- 
wards and  from  before  backwards,  with  a  depression  in  front  of 
each  side  produced  by  the  over-riding  of  the  posterior  fragment. 

"  The  left  arytenoid  cartilage  presented  an  incomplete  luxa- 
tion, and  was  in  a  plane  anterior  to  the  posterior  border  of  the 
cricoid  cartilage.  The  transverse  arytenoid  muscle  was  infil- 
trated with  a  sanguinolent  serum. 

"  The  examination  of  the  interior  of  the  larynx  showed  the 
existence  of  a  very  considerable  osdema  of  the  glottis,  of  the 
aryteno-glottic  ligaments,  the  vocal  cords,  and  the  epiglottis. 
The  left  ventricle  of  the  larynx  was  completely  effaced,  and 
the  entire  mucous  membrane  of  the  larynx  strongly  injected. 

"  The  lungs  were  of  a  violaceous  color,  with  numerous  sub- 
pleural  ecchymoses.  There  was  but  slight  crepitation  of  the 
inferior  portion  of  the  lungs.  Incisions  made  into  the  pul- 
monary parenchyma  gave  escape  to  a  large  quantity  of  very 
black  blood. 

"  IS^o  lesion  in  the  heart ;  its  cavities  were  empty. 

"  The  liver  was  very  much  hypertrophied  and  strongly  con- 
gested; there  was  considerable  escape  of  black  blood  on  cut- 
ting into  it. 

"  The  sudden  death  in  this  instance  seemed  to  have  been  the 
result  of  the  sudden  displacement  of  a  fragment  of  the  cricoid 
cartilage  and  the  corresponding  arytenoid  cartilage,  which  in 
the  movement  made  b}^  the  patient  had  over-ridden  the  other, 
making  an  immediate  obstacle  to  the  passage  of  atmospheric 
air,  and  producing  death  by  asphyxia." 

Several  cases  of  a  similar  character  are  on  record,  in  which 
death  occurred  during  the  course  of  treatment,  and  in  which  it 
is  likely  that  a  successful  result  would  have  been  obtained,  had 
an  artificial  opening  into  the  air-passages  formed  an  integral 
part  of  the  early  treatment. 


FEACTURE  OF  THE  TEACHEA.  493 

Fracture  of  the  Tracheal  Cartilages. — Fracture  of  the 
cartilages  of  the  trachea  occurs  under  the  same  circumstances  as 
fracture  of  the  larynx,  sometimes  without  simultaneous  fracture 
of  the  larynx  or  hyoid  bone,  but  oftener  in  connection  with  a 
similar  inj  urj  to  these  organs.  Giirlt  gives  nine  cases  of  fracture 
of  the  tracheal  cartilage,  in  four  of  which  the  fracture  involved 
the  trachea  alone,  while  in  the  other  five  it  was  combined  with 
fracture  of  the  hyoid  bone  and  larynx.  His  principal  remarks 
are : — 

"  The  causes  of  the  isolated  fracture  of  the  trachea  were : 
direct  violence  to  the  throat  by  pressure  of  a  solid  body,  such 
as  a  wagon,  the  buffer  of  a  railroad-car,  blows  upon  the  throat 
with  the  fist  or  with  a  foreign  body. 

"  The  general  symptoms  are  very  similar  to  those  of  fracture 
of  the  larynx,  with  which  it  is  so  often  associated — severe  dys- 
pnoea and  rapidly  extending  emj^hysema ;  but  the  local  symptoms 
are  much  more  difticult  to  distinguish,  for  there  is  no  palpation  of 
the  dislocated  fragments,  no  abnormal  mobility  or  crepitation ; 
the  latter  symptom  is  easier  rendered  in  the  presence  of  extra- 
vasation of  blood  or  emphysema. 

"  The  diagnosis,  therefore,  is  difficult  as  far  as  regards  the 
nature  and  seat  of  the  injury,  though  it  can  generally  be  made 
out  from  the  general  symptoms,  and  by  exclusion. 

"  The  prognosis  of  the  injury  is  unfavorable,  as  it  is  in  severe 
injuries  of  the  larynx;  and  the  accident  leads  without  abatement 
to  rapid  death,  although,  in  a  few  cases,  life  may  be  saved  by 
prompt  operative  interference.  Of  seven  cases  collected  by 
Giirlt,  in  five  of  them  death  followed  in  1^,  3, 12  hours,  and  on 
the  day  following  that  of  the  accident.  In  one  only,  in  a  patient 
apparently  dead  at  the  time,  was  life  saved  by  tracheotomy,  fol- 
lowed by  the  removal  of  masses  of  blood  and  mucus  that  liad 
accumulated  in  the  air-passages,  and  by  the  institution  of  artifi- 
cial respiration. 

"  The  treatment  must  be  similar  to  that  adopted  in  fracture 
of  the  larynx,  and  consists  principally  in  promptly  laying  the 
wounded  part  freely  open,  when  its  anatomical  position  permits 
it,  and  especially  in  extensive  transversal  laceration  of  the 
trachea,  and  the  consequently  possible  dislocation  of  both  frag- 


494      AFFECTIONS    OF  (THE    LAEYNX    AND    TEACHEA. 

ments,  whicli  may  interrupt  or  compromise  the  access  of  tlie 
atmosphere  to  the  hmgs,  a  circmnstance  under  which  life  can 
continue  for  a  very  short  time  only. 

"  Although  no  observations  of  the  kind  have  been  made,  it  is 
likely  that  the  free  laying  open  of  the  torn  trachea  will  secure 
the  passage  of  the  air  to  the  lungs,  and  avoid  the  most  imminent 
danger  to  life.  Recovery  would  then  take  place  in  the  same 
manner  as  it  would  after  a  horizontal  section  of  the  trachea 
made  in  an  attempt  at  suicide.  Union  of  the  wound  by  suture 
is  to  be  avoided,  and  union  by  suppurative  inflammation  to  be 
awaited,  union  being  promoted  by  a  proper  position  given  to 
the  head." 

Rupture  of  the  Trachea. — In  addition  to  fracture  of  its  car- 
tilages, and  sometimes  independently  of  it,  the  trachea  is  liable 
to  undergo  laceration  as  the  result  of  accident  or  personal 
injury,  a  rupture  taking  place  either  between  two  of  its  rings, 
or  between  its  upper  ring  and  the  larynx.  Dyspnoea  and  em- 
physema of  the  neck  are  the  main  diagnostic  symptoms.  Several 
instances  of  rupture  of  the  trachea  are  on  record,  most  of  which 
terminated  fatally.  In  one  instance  recorded  by  Dr.  Lauenstein,^ 
the  patient  made  a  good  recovery  from  a  rupture  of  the  trachea 
resulting  from  the  kick  of  a  horse ;  the  only  symptoms  remain- 
ing being  a  croup-like  cough,  pain  on  pressure,  and  dyspnoea  on 
attempt  at  motion.  Mr.  Long,^  of  Liverpool,  relates  a  case  in 
which  the  windpipe  of  a  laboring  man  was  completely  torn  from 
the  larynx  by  his  being  caught  round  the  neck  by  the  coupling 
irons  connecting  two  railway  carriages.  On  the  fifth  day  tra- 
cheotomy became  necessary,  which  saved  the  patient's  life. 
During  the  operation  it  became  apparent  that  the  trachea  had 
become  separated  from  the  larynx  for  the  distance  of  about  two 
inches.  The  tracheotomy  tube  was  removed  on  the  ninth  day. 
Prof.  Gross,^  gives  a  case  occurring  to  Dr.  Thomas  Marshall,  of 
Va.,  of  spontaneous  laceration  of  the  trachea,  through  despe- 
rate inspiratory  efforts  of  the  j)atient  to  relieve  the  dyspncea 

1  Am.  Jour.  Med.   ScL,  Oct.,  1871,  p.  561,   (from  CentralUatt  f.  d.  Med. 
F'm.,Dec.  17,  1870.) 
'  Med.  Times,  July  26,  1856. 
^  Pathological  Anatomy. 


FRACTURE  0^    THE  TRACHEA.  495 

caused  by  the  pressure  of  a  large  thoracic  aneurism.  An  in- 
stance is  noticed  by  Beck/  of  a  boy  whose  trachea  was  totally 
divided  by  getting  his  throat  jammed  against  a  post  in  a  coal-pit. 
Bredschnider^  records  the  case  of  a  male  infant,  ?et.  If  years, 
who  had  become  very  unmanageable  during  an  attack  qf  bron- 
chitis, and  tossed  his  head  about  in  a  very  powerful  manner, 
inducing  a  comatose  condition  that  gradually  increased  ;  on  the 
fifth  day  an  emphysema  began  under  the  cricoid  cartilage,  and 
rajDidly  extended  itself  on  both  sides.  The  air  was  alforded 
egress  by  incision.  The  autopsy  showed  a  small  slit  beneath 
the  first  cartilaginous  ring,  stretching  from  the  right  side  to  its 
middle.  Dr.  John  L.  Atlee,^  of  Lancaster,  Pa.,  relates  a  case 
from  a  fall,  occurring  in  a  boy  four  years  of  age.  Ryland*  men- 
tions a  case  recorded  by  Dr.  O'Brien  in  18th  vol.  of  the  Edinh. 
Med.  and  Surg.  Jour,  of  a  woman  who  had  been  kicked  under 
the  jaw.  She  died,  and  on  post-mortem  examination  a  rupture 
w^as  found  extending  from  a  similar  injmy  of  the  thyroid  and 
cricoid  cartilages  of  the  larynx,  through  the  right  side  of  the 
first  ring  of  the  trachea.  Dr.  Robertson,^  of  Wiesbaden,  re- 
cords a  case  of  complete  rupture  of  the  trachea  from  the  larynx, 
occurring  in  the  person  of  a  Prussian  artillerist,  injured  by  the 
kick  of  a  horse.     The  laryngeal  cartilages  were  uninjured. 

Contusions  of  the  Larynx  and  Trachea. — Contusions  of 
the  larynx  or  trachea  are  sometimes  produced  as  the  result  of 
accident  or  external  violence.  They  are  not  usually  very  se- 
rious in  their  nature.  Their  treatment  would  consist  in  rest  of 
the  parts,  soothing  applications  externally  and  careful  watching. 
Dr.  Le  Gros  Clark  ^  records  a  case  of  contusion  from  a  blow, 
which  produced  pain  on  motion  of  the  parts,  and  pain  on  swal- 
lowing.     There  was  also  complete  aphonia.      There  was  no 

'  Medical  Jurisprudence,  1st.  Ed.  p.  718. 

^  (Casper's  WoGhensc7i7'ift  fur  die  gesammte  IleilMcjide,  1842,  ^.  461.)  G-iirlt, 
op.  cit. ,  p.  336. 

=  Am.  Jour.  Med.  Sd.,  Jan.,  1858,  p.  120. 

.  ■•  A  Treatise  on  the  Diseases   and   Injuries   of  che  Larynx  and  Ti  achea. ' 
PMla.  Ed.,  1838,  p.  177. 

"  Lancet,  Sept.  6,  1856. 

"  Lectures  on  Surgery,  1870,  p.  229. 


496       AFFECTIOlSrS    OF    THE    LAEYiN^X   AIS^D    TEACIIEA. 

blood  in  the  sputa.     The  voice  began  to  return  in  ten  days,  and 
the  patient  was  well  in  three  weeks. 

A  contusion  of  the  larynx  may  produce  spasm  of  the  glottis, 
threatening  suffocation,  and  thus  rendering  the  operation  of 
laryngotomy  or  tracheotomy  necessary.  Contusions  in  this 
region  are  sometimes  attended  with  severe  injury  to  the  soft 
parts.  Dr.  Louis  Stromeyer  ^  states  that  he  has  seen,  after  an 
accident  of  this  kind,  a  spasmodic  retraction  of  the  muscles  of 
the  neck  lasting  for  several  days,  so  that  the  head  was  bent 
backwards  as  in  opisthotonos,  and  could  hardly  be  moved. 
Eest  and  suitable  outward  applications  quieted  the  condition, 
and  the  patient  recovered  without  any  untoward  symptoms. 

ARTiriCLAX,    OPENINGS    INTO    THE    LAETNX    AND    TRACHEA. 

A  necessity  arises,  not  infi-equently,  for  making  an  artificial 
opening  into  the  air-passages,  for  the  purpose  of  securing  free 
access  of  air  to  the  lungs  in  cases  of  impending  or  actual  suf- 
focation. 

Such  a  necessity  may  arise  from  the  presence  of  a  foreign 
body  in  the  larynx,  trachea,  or  bronchi ;  in  acute  lai-}-ngitis, 
whether  idiopathic  or  traumatic ;  in  oedema  of  the  larynx ;  in 
glossitis,  tonsillitis,  and  retro-pharyngeal  abscess  ;  in  croup  and 
diphtheria ;  in  fracture  and  other  wounds  of  the  larynx,  or  rup- 
ture of  the  trachea  ;  in  neoplasms  in  the  larynx  or  trachea ;  in 
large  neoplasms  or  imj^acted  foreign  bodies  in  the  j)harynx  or 
oesophagus  ;  in  tumors  outside  of  the  air  tube  but  pressing  inju- 
riously upon  it ;  in  ulceration  and  necrosis  of  the  cartilages  in 
tuberculosis  and  syphilis  ;  in  contractions  of  the  caliber  of  the 
larynx  or  tracliea  the  result  of  cicatrization  ;  in  asphyxia  ;  and 
occasionally  in  laryngismus  stridulus,  in  spasm  of  the  glottis  in 
epilejDsy  and  tetanus,  and  in  certain  cases  of  aneurism  of  the  aorta. 

The  indications  for  such  procedure  under  the  circumstances 
enumerated  are  given  under  their  respective  heads.  In  the 
present  place  we  have  to  speak  of  the  operation  itself,  and  its 
consequences. 

Three  operations  are  performed  to  secure  an  artificial  opening 
into  the  air-passages,  and  they  are  usually  described  under  the 

'  Verletzungen  imd  chirurgische  Kraiikheiten  des  Halsgegend,  1865,  p.  309. 


ARTIFICIAL    OPEIfllTGS    INTO    THE    AIE-PASSAGES.      497 

caption  of  broncliotoraj,  a  term  to  whicli  we  shall  not  again 
refer  in  this  connection.  These  operations  are  laryngo- 
tomy,  partial  or  complete  ;  laryngo-tracheotomy,  and  tracheo- 
tomy. 

Laryngotomy  is  nsually  confined  to  making  an  opening  in  the 
crico-thyroid  membrane  in  acute  cases,  where  an  artificial  oipen- 
ing  is  required  for  a  short  time  only.  Such  cases  are  acute 
laryngitis ;  oedema  of  the  larynx ;  fracture  of  the  larynx ;  the 
safe  removal  of  an  extensive  neoplasm  under  laryngoscopic  ma- 
nipulation ;  the  extraction  of  small  foreign  bodies  from  the 
larynx  when  their  position  has  been  determined  by  the  laryn- 
goscope or  otherwise. 

This  operation  is  nsually  performed  upon  adults  only.  For 
the  removal  of  large  foreign  bodies,  or  large  neoplasms  from  the 
larynx,  and  in  certain  cases  of  extensive  traumatic  injury,  it  is 
sometimes  necessary  to  lay  open  the  entire  larjmx ;  and  some- 
times to  divide  the  thyroid  cartilage  merely.  This  latter  oper- 
ation is  called  thyrotomy.  There  is  still  another  form  of  laryn- 
gotomy, which  has  been  occasionally  resorted  to  in  cases  of 
foreign  growths  in  the  larynx,  and  this  consists  in  a  transverse 
entrance  known  as  sub-hyoidean  laryngotomy. 

When  the  cricoid  cartilage  and  one  or  more  rings  of  the  tra- 
chea are  involved  in  the  artificial  opening,  the  operation  is 
known  as  laryngo-tracheotomy. 

When  the  trachea  alone  is  opened,  the  operation  is  known  as 
tracheotomy. 

The  opening  being  made,  it  is  often  necessary  to  maintain  it 
in  a  patulous  condition  for  a  certain  or  uncertain  period.  This 
is  accomplished  by  removing  a  circular  section  of  the  tube ;  or 
by  keeping  the  edges  apart  by  blunt  hooks  secured  around  the 
neck  ;  or  by  the  insertion  of  a  tracheotomy  tube  or  canule.  In 
the  latter  instance  an  outer  tube  is  fastened  round  the  neck,  and 
an  inner  tube,  the  end  of  which  projects  beyond  the  outer  one 
(fig.  129),  placed  within  it,  so  that  it  can  be  removed  at  will,  for 
the  purpose  of  cleansing  it  from  the  congealed  mucus,  blood, 
and  sputa,  which  are  apt,  under  certain  circumstances,  to  accu- 
mulate within  it  and  clog  it,  so  as  to  oifer  a  fresh  impediment 

to  the  free  access  of  air  to  the  trachea. 
32 


498   AFFECTIONS  OF  THE  LAEYNX  AND  TRACHEA. 


Fig.  129. 


The  necessity  for  performing  tracheotomy  on  the  instant 
sometimes  occnrs  when  the  surgeon  is  not 
provided  with  proper  instruments,  or  with 
a  tracheotomy  tube  for  insertion  after  the 
operation.  In  these  imperative  cases  delay 
of  any  kind  would  be  fatal,  and  the  opera- 
tion must  be  performed  promptly  and  at  all 
hazard.  Should  the  case  terminate  unfa- 
vorably, the  surgeon  must  be  able  and 
willing  to  bear  the  responsibility  of  his 
action.  This  is  one  of  the  sacrifices  that 
professional  duty  sometimes  exacts  from  us. 
Trousseau's  double  tracheot-  ft  is  part  of  the  cost  of  practisiuoj  mcdi- 

omy  tube.  -'-  x  o 

cine.  Better  to  make  the  attempt  to  save 
life  and  fail,  than  to  look  supinely  upon  the  final  agony  with 
one's  hands  in  his  pockets.  The  occasions  for  this  sudden  inter- 
ference occur  sometimes  in  the  course  of  regular  practice,  but 
more  often  at  the  dining-table  or  upon  the  street,  or  upon  some 
occasion  when  the  physician  is  present  as  a  spectator,  but  not  in 
his  professional  capacity.  If  he  sees  a  person  suffocating  from 
strangulation  and  is  unable  to  set  the  cause  aside,  it  is  his  im- 
perative duty  to  open  the  trachea  or  larynx  by  one  bold  incision  ; 
with  his  pocket-knife,  if  he  have  no  other  instrument  by  him. 
The  knife  maybe  plunged  into  the  crico-thyroid  space,  and  then 
turned  around  in  the  cut  to  enlarge  the  opening  for  the  access 
of  air.  There  is  no  time  for  dissection,  and  if  the  patient  is 
not  rescued  it  will  not  have  been  from  neglect  of  the  surgeon. 
Suppose  an  arterial  branch  be  wounded;  the  operator  must 
incur  the  risk  of  wounding  it.  A  quill,  a  tooth-pick,  a  tube 
from  the  barrel  of  a  pencil-case,  answers  the  purpose  of  a  tem- 
porary canule  until  a  suitable  one  can  be  procured  ;  and  until  this 
substitute  is  in  readiness  for  insertion,  the  wound  is  kept  patu- 
lous by  retaining  the  knife  crosswise  in  it. 

An  admirable  tracheotomy  tube  in  a  case  of  emergency,  one 
which  can  be  made  in  a  few  moments,  has  been  recently  intro- 
duced to  the  notice  of  the  profession  by  Dr.  Benjamin  Howard, 
of  New  York,'  who  extemporized  it  for  the  first  time  during  an 
1  TU  Medical  Beaord,  Nov.  1871,  p.  391. 


ARTIFICIAL  OPENIlSrGS  INTO  THE  AIR-PASSAGES.       499 


Fig.  130. 


emergency  which  happened  while  on  a  shooting  excursion.  It 
is  a  regular  tracheotomy  tube  made  out  of  lead,  a  metal  almost 
always  accessible  in  some  form  or  other ; 
the  material  having  been  a  Minie  bullet 
on  the  occasion  referred  to.  The  direc- 
tions of  Dr.  Howard  are  as  follows : — 

"  Take  a  piece  of  lead,  whether  in  the 
form  of  sheet,  pipe,  or  bullet,  and,  if 
necessary,  hammer  it  out  as  thin  as  it 
can  be  used  without  breaking.  Of  this 
cut  a  piece  the  shape  of  a  parallelogram 
about  two  and  a  half  by  one  and  a  quar- 
ter inches,  or  enough  larger  to  allow  a 
margin ;  roll  it  around  a  trimmed  stick, 
ramrod,  or  pencil,  thus  making  a  tube  as 
in  Fig.  130,  and  level  both  edges  so  that, 
by  trimming  and  dressing,  the  seam  may 
be  smooth  and  firm.     Cut  the  upper  end 

Pig.  131. 


The  sheet  of  lead  rolled  around 
a  pencil,  cl. — aa,  Seam  down  cen- 
tre bevelled  and  dressed  smooth. 
—bb,  Slips  cut  at  upper  end  of 
tube,  to  be  turned  down  as  at  bb, 
fig.  131,  two  of  them  being  there 
pierced  with  eyelet-holes. — cc. 
Section  cut  out  transversely 
from  two-thirds  the  circumfe- 
rence of  the  tube,  which  at  c,  fig. 
131,  is  bent  upon  itself. 


Leaden  Canula. — bb,  Flange  and 
eyelet-holes.— c,  Joint  where  tube  is 
bent  on  itself. 


SO  as  to  form  four  slips  of  equal  size,  h  1)  ;  and  at  about  the  middle 
of  the  tube  cut  out  a  transverse  elliptical  section  from  about 
two-thirds  of  its  circumference  (fig.  130  c  c).      Withdraw  the 


500        AFFECTIONS    OF   THE    LAEYJSTX   AND    TEACIIEA. 

pencil  and  bend  tlie  tube  upon  itself.  Turn  down  tlie  slips, 
and  in  two  of  them  cut  eyelet-holes  through  which  a  string  or 
tape  may  be  passed  around  the  neck,  to  retain  the  canula  in  its 
position  in  the  wound." 

A  similar  device  was  resorted  to  by  Prof.  Trousseau  in  1828, 
and  is  mentioned  in  his  lectures.' 

Laryngotomy.— The  position  of  the  crico-thyroid  ligament 
being  determined  by  the  touch,  an  incision,  fi'om  an  inch 
to  an  inch  and  a  half  in  length,  is  made  in  the  middle  line, 
so  that  its  central  third  shall  expose  the  ligament,  the  incision 
dividing  the  skin  and  cervical  fascia.  The  parts  may  be  made 
tcLse  between  the  thumb  and  lingers  of  the  disengaged  hand,  or 
they  may  be  pinched  up  into  a  transverse  fold  aixl  be  divided 
after  transfixion  of  the  base  of  the  fold.  The  ligament  is  then 
freed  of  any  superimposed  tissue  not  divided  by  the  first  inci- 
sion, great  care  being  taken  to  avoid  wounding  the  communicating 
branch  of  the  two  thyroid  arteries  VN^hich  may  be  in  the  way, 
and  which  is  to  be  shoved  to  one  side,  twisted,  or  divided  between 
a  double  ligature  cast  around  it,  as  the  peculiarity  of  the  case 
may  determine.  The  ligament  is  then  divided  by  a  horizontal 
or  vertical  section,  according  to  the  nature  of  the  case,  and  if  the 
opening  thus  made  is  insuificient,  it  is  to  be  split  crosswise.  When 
an  opening  into  the  ligament  is  not  large  enough  for  the  purpose 
required,  the  cricoid  cartilage  is  to  be  divided,  and,  if  need  be, 
even  a  portion  of  the  thyroid  cartilage,  care  being  taken  in  the 
latter  operation  to  avoid  wounding  the  vocal  cords.  Care  must 
be  taken  not  to  injure  the  posterior  wall  of  the  larynx  with  the 
point  of  the  knife,  and  also  not  merely  to  push  before  it  the 
anterior  laryngeal  mucous  membrane,  which  is  sometimes  de- 
tached from  the  ligament.  Entrance  into  the  cavity  of  the 
larynx  is  denoted  by  a  peculiar  whizzing  sound  and  the  escape 
of  air,  mucus,  and  blood  from  the  opening. 

Tracheotomy. — This  operation  may  be  performed  most  ex- 
peditiously in  the  following  manner,  which,  in  its  essential 
points,  is  that  recommended  by  Prof.  Langenbeck  : — 

The  operator  standing  at  the  right  side  of  the  patient,  and 

^  Lectures  on  Clinical  Medicine,  Sydenham  So.  Edition,  Vol.  II.  p.  489. 


ARTIFICIAL    OPElSrilSrGS    INTO    THE    AIR-PASSAGES.      501 

a  skilled  assistant  at  the  left,  an  incision  is  made  into  the 
skin  and  subjacent  fascia,  either  by  rendering  the  integuments 
tense,  or  by  pinching  up  a  transverse  fold  of  tissue.  This  inci- 
sion extends  from  the  cricoid  cartilage  to  about  within  a  third 
or  fourth  of  an  inch  from  the  top  of  the  sternnm,  being  from  an 
inch  and  a  half  to  two  inches  in  length.  Any  arteries  wounded 
in  this  incision  being  secured,  the  operator  seizes  the  subcuta- 
neous comiective  tissue  with  a  pair  of  sharp-toothed  forceps  on 
one  side  of  the  middle  line  and  parallel  to  it ;  the  assistant 
seizes  it  in  like  manner  at  a  corresponding  point  on  the  oppo- 
site side,  and  the  two  raise  the  fold  of  fascia,  which  is  then  di- 
vided by  the  operator.  In  this  way  they  proceed  with  fold  after 
fold,  taking  care  to  press  the  large  veins  aside  as  well  as  may 
be,  and,  when  they  cannot  be  avoided,  to  ligate  them  in  two 
places  and  cut  between  the  ligatures.  The  sterno-hyoid  and 
sterno-thyroid  muscles  are  then  separated  by  the  handle  of  the 
knife,  with  as  little  use  of  the  blade  as  possible,  exposing 
the  upper  portion  of  the  trachea,  which  is  usually  covered  by 
the  isthmus  of  the  thyroid  gland.  This  structure  is  avoided, 
when'  practicable,  by  pushing  it  upwards,  or  by  endeavoring  to 
reach  the  trachea  from  below  it ;  but  if  this  cannot  be  done 
with  safety,  two  ligatures  are  thrown  around  it,  and  it  is  then 
di-sdded  between  them.  During  all  this  time,  an  assistant  at 
the  head  of  the  patient  keeps  the  field  of  023eration  clear  from 
blood  with  small  pieces  of  sponge  tied  to  a  stick,  or  held  in  for- 
ceps. As  soon  as  the  trachea  has  been  fully  exposed,  a  sharp 
tenaculum  is  thrust  into  it,  and  it  is  raised  somewhat  upwards, 
and  steadied,  when  it  is  divided  from  below  upwards  in  three 
or  four  of  its  upper  rings  by  a  sharp-pointed  bistomy,  inserted 
into  one  of  the  interspaces.  Care  must  be  taken  to  penetrate 
the  mucous  membrane  of  the  trachea  on  the  one  hand,  and 
to  avoid  striking  the  posterior  wall  on  the  other.  The  fact  of 
penetration  is  confirmed  by  the  peculiar  hissing  sound  with 
which  the  air  rushes  out  of  the  wound,  and  by  the  convulsive 
cough  which  shoots  the  blood  and  mucus  out  to  a  great  dis- 
tance. The  operator  now  seizes  the  edge  of  the  tracheal  wound 
upon  the  left  side  with  a  pair  of  toothed  slide-forceps,  closes 
the  slide,  and  hands  the  instrument  to  his  assistant,  when  with 


502       AFFECTIONS    OF    THE    LARYNX    AND    TEACHEA. 

a  similar  pair  of  forceps  lie  secures  the  other  border.  Slight 
traction  being  now  made,  the  edges  of  the  wound  are  separated ; 
and  if  the  canule  is  to  be  employed,  it  is  then  introduced.  If 
the  trachea  has  not  been  opened  sufficiently,  it  is  again  raised 
up  from  the  bottom  of  the  wound,  and  the  opening  is  enlarged 
with  a  probe-pointed  bistoury,  care  being  taken  that  no  vessels 
are  in  the  path  of  the  knife. 

Hemorrhage  is  restrained  by  small  pieces  of  ice  enclosed  in 
a  fold  of  towel  or  napkin,  and  held  in  contact  with  the  bleeding 
surfaces.  Should  this  not  suffice,  the  bleeding  vessels  should 
be  sought  for  and  secured  by  ligature.  As  a  rule,  the  hemor- 
rhage should  be  controlled  before  the  incision  is  made  into  the 
trachea,  and  for  obvious  reasons.  If  the  hemorrhage  is  merely 
venous  and  due  to  the  existing  impediment  in  respiration,  the 
trachea  may  be  divided  at  once  and  the  tube  be  introduced, 
when,  with  the  free  access  of  air,  the  ordinary  course  of  the 
circulation  will  be  resumed,  and  the  hemorrhage  will  usually 
cease  spontaneously ;  indeed  many  authors  state  that  it  will 
always  be  arrested  at  once.  The  hemorrhage  is  sometimes  very 
great,  even  when  there  have  not  been  any  anomalous  vessels  in 
the  way  to  complicate  the  operation  ;  at  other  times,  the  action 
of  the  circulatory  system  has  become  so  much  enfeebled  by  the 
want  of  air,  that  the  hemorrhage  is  insignificant. 

A  good  deal  of  spasmodic  disturbance  attends  the  introduc- 
tion of  the  tube,  which  renders  it  sometimes  difficult  to  retain 
it  in  position  while  securing  it  to  the  neck ;  but  this  usually 
passes  of£  in  a  few  minutes. 

Sometimes  considerable  difficulty  is  encountered  in  intro- 
ducing the  tracheotomy  tube.  Sometimes  this  occurs  from  the 
insufficiency  of  the  artificial  opening,  and  sometimes  from  the 
resiliency  of  the  cartilages.  I  have  never  had  any  difficulty  of 
this  kind,  and  have  usually  placed  a  tenaculum  in  the  wound 
upon  one  side,  while  an  assistant  placed  another  on  the  other 
side,  and  then  by  gentle  traction  the  edges  of  the  wound  were 
separated,  and  the  tube  slid  down  between  the  posterior  faces 
of  the  two  instruments  which  guided  the  canula  safely  and 
speedily  into  the  trachea.  Some  surgeons  secure  the  trachea 
on  each  side  by  a  ligature ;  divide  it  between  the  two  ligatures, 


AETIFICIAL  OPENINGS  INTO  THE  AIE-PASSAGES.       503 


Fig.  132. 


Trousseau's  Dilator  for  use 
in  Tracheotomy. 


and  separate  the  lips  of  the  wound  by 
drawing  on  the  ligature.  It  is  possible,  by 
drawing  the  edges  of  the  wound  too  far 
apart,  to  so  flatten  the  caliber  of  the  trachea 
as  to  prevent  the  insertion  of  the  tube  for 
mere  want  of  room. 

Prof.  Trousseau  long  ago  devised  a  special 
dilator  (fig.  132)  for  the  tracheal  wound  and 
the  guidance  of  the  canula,  which  is  consid- 
ered by  some  surgeons  as  an  indispensable 
requisite  in  the  operation.  The  instrument 
is  introduced  into  the  wound  closed,  its 
branches  are  then  separated,  and  the  trache- 
otomy tube  slid  down  between  them.  The 
ends  of  the  blades  are  turned  in  opposite  directions,  and  thus 
facilitate  the  movement  of  the  canula. 

After  the  tube  has  been  inserted,  and  respiration  is  quiet, 
the  edges  of  the  external  wound  above  and  below  the  tube  are 
brought  together  by  adhesive  strips,  care  being  taken  to  leave 
the  lower  end  of  the  wound  patulous  for  drainage.  A  piece 
of  oiled  silk  is  slit  and  slipped  under  the  shoulders  of  the 
tracheotomy-tube,  to  prevent  it  fi'om  rubbing  the  skin;  and 
the  wound  is  dressed  with  cold  water  or  with  a  greased  rag,  at 
the  fancy  of  the  operator. 

A  piece  of  gauze  or  mnslin  is  then  straddled  upon  a  piece  of 
adhesive  plaster,  and  secured  at  the  upper  portion  of  the  neck. 
This  protects  the  tube  from  dust,  and  modifies  the  temperature 
of  the  inspired  air  by  retaining  some  of  the  warmth  of  the 
breath  of  expiration.  The  dressing  may  be  attached  to  the 
neck  in  the  same  manner.  It  saves  the  discomfort  of  tying 
bands  around  the  patient's  neck,  and  admits  of  ready  inspection 
of  the  parts.  This  mode  of  dressing  was  brought  to  my  notice 
by  Dr.  Packard. 

As  long  as  the  patient  is  confined  to  his  room,  which  ought 
always  to  be  for  four  or  five  days  at  least,  the  apartment  should 
be  kept  warm,  at  a  temperature  of  not  less  than  80°  F.,  and  even 
upwards,  85°  to  90°  at  times  with  advantage,  the  heat  being  regu- 
lated by  a  thermometer;  and  more  or  less  of  an  atmosphere 


504       AFFECTIONS    OF    THE   LAEYNX   Al^D    TEACHEA. 

loaded  witli  steam  should  be  secured  by  some  of  the  means 
narrated  in  connection  with  the  subject  of  croup.  This  lessens 
in  great  measure  any  risk  of  bronchitis  or  pneumonitis,  a  risk 
which  is,  23erhaps,  always  present  in  a  greater  or  less  degree. 

■  For  the  first  twenty-four  hours,  the  inner  canule  should  be  re- 
moved every  two  or  three  hours  and  be  immersed  in  warm  water, 
for  the  solution  of  the  gummy  deposits  which  adhere  to  it,  and  it 
should  not  be  reintroduced  until  after  the  outer  tube  has  been 
cleansed  in  position,  by  means  of  a  feather,  or  a  linen  or  sponge 
mop,  securely  fastened  to  a  whalebone  or  other  stem.  The  re- 
moval and  insertion  of  the  inner  canule  very  often  provoke 
spasmodic  cough  at  first ;  this  can  be  lessened,  in  the  latter  in- 
stance, by  warming  the  tube  before  introducing  it.  After  the 
first  twenty-four  or  forty-eight  hours,  there  is  rarely  occasion 
to  remove  the  inner  tube  more  than  three  or  four  times  a'  day, 
unless  it  become  occluded,  a  condition  which  will  become  evident 
by  the  sensations  of  the  patient,  or  his  movements,  if  too  young 
to  express  them.  When  it  is  proposed  to  remove  the  canula 
]3ermanently,  a  finger  is  j)laced  upon  its  orifice,  to  ascertain 
whether  the  patient  can  breathe  comfortably  througli  the  larynx 
with  the  air  that  passes  by  the  side  of  it ;  and  if  this  appear  to 
be  the  case,  the  tube  is  withdrawn,  but  kept  within  easy  reach 
for  reintroduction  if  necessary.  The  external  wound  usually 
closes  promptly  Mdthout  any  interference. 

Should  fungous  granulations  present  at  the  wound  at  any  time, 
they  are  to  be  repressed  by  local  applications  of  tannin,  gallic 
acid,  or  nitrate  of  silver ;  or  if  extensive,  they  are  to  be  snipped 
off  and  their  bases  cauterized. 

The  use  of  tracheotomes  is  unsurgical,  and  sometimes  haz- 
ardous. 

The  operations  of  laryngotomy  and  tracheotomy  may  he  per- 
formed with  the  patient  in  the  recumbent  or  semi-recumbent 
position,  as  circumstances  may  dictate. 

The  head  should  be  thrown  somewhat  back  and  the  shoulders 
elevated,  so  as  to  render  the  larynx  and  trachea  prominent ;  but 
care  must  be  taken  not  to  throw  the  head  back  too  far,  and  thus 
compress  the  trachea  and  impede  respiration. 


CATHETEEIZATIOISr    OF    THE    LAETJSTX,  ETC.  505 


CATHETERIZATION    OF    THE   LAETXX   A]SD    TRACHEA. 

Catheterism  of  the  upper  air-passage  is  occasionally  resorted 
to  in  cases  of  mechanical  obstruction  to  the  entrance  of  air, 
other  than  that  produced  by  the  presence  of  a  foreign  body. 
This  may  occur  from  stenosis  within  the  larynx  or  trachea ; 
from  external  pressure  upon  the  trachea ;  from  paralysis  of  the 
muscles  opening  the  glottis ;  or  fi-om  spasmodic  closure  of  the 
glottis.  It  is  also  resorted  to  for  the  purpose  of  practising 
injections  into  the  trachea  or  bronchi.  A  simple  elastic 
catheter  of  large  size  and  sufficiently  long  (about  12  inches), 
is  usually  employed  for  this  purpose.  This  method  was  much 
employed  for  injecting  the  bronchi  or  pulmonary  cavities  by 
the  late  Prof.  Horace  Green,  of  N"ew  York,  who  recommend- 
ed bending  the  catheter  to  a  suitable  curve  and  then  diiDping  it 
in  cold  water,  to  give  it  sufficient  stiifness  to  do  away  with  the 
use  of  the  metallic  guide.  The  French  surgeons  prefer  a  silver 
instrument.  Care  must  be  taken  that  the  instrument  is  not 
passed  into  the  oesophagus.  With  the  aid  of  the  larjmgo&copic 
mirror  a  mistake  of  this  kind  can  be  avoided. 

In  cases  where  the  catheter  is  to  be  retained  for  any  length 
of  time,  its  presence  in  the  mouth  is  often  very  uncomfortable. 
On  this  account  it  has  been  recommended  to  allow  the  upper 
end  of  the  catheter  to  protrude  through  one  of  the  nostrils,  which 
is  accomplished  by  fastening  it  to  the  staff  of  aBellocq's  canula 
passed  through  the  nostril.  Sometimes  the  catheter  cannot  be 
directed  into  the  trachea  through  the  mouth,  and  it  is  then  recom- 
mended to  pass  it  through  the  nostril  in  the  first  instance,  a 
procedure  usually  more  embarrassing,  but  sometimes  not  difficult 
of  accomplishment. 

When  the  catheter  has  entered  the  trachea,  there  is  usually 
pain,  cough,  spasm,  loss  of  voice,  and  egress  of  air  through  the 
tube.  All  these  symptoms  may  be  produced  with  the  catheter 
in  the  oesophagus, 

AFFECTIOXS    OF    THE   LARYNGO-PHARTISiGEAL    SIISTUS. 

Particles  of  food  will  sometimes  lodge  in  the  pyrif orm  sinuses 
and  give  rise  to  ulcerative  inflammation.     Fish-bones  sometimes 


506       AFi^ECTIO]N^S    OF    THE    LARYNX   AIs^D    TRACHEA. 

tear  the  mucous  membrane  in  their  passage  to  the  oesophagus. 
The  sensations  of  this  lesion  are  a  more  or  less  continuous  prick- 
ing as  by  the  presence  of  a  sharp  or  pointed  body,  more  particu- 
larly on  swallowing,  also  on  coughiug,  sneezing,  or  any  move- 
ment of  the  parts,  such  as  stretching  the  tongue.  The  abraded  or 
divided  surfaces  are  put  upon  the  stretch,  giving  rise  to  the  pain. 
There  is  usually  a  more  or  less  copious  secretion  of  mucus  in 
the  sinus,  sometimes  filling  it,  and  hiding  the  affected  spot 
from  view.  A  sponge  plunged  into  the  sinus  will  absorb  this 
fluid,  and  the  parts  can  then  be  examined. 

The  passage  over  the  parts  of  a  sponge  dipped  into  a  solution 
of  nitrate  of  silver  will  soon  eradicate  the  entire  trouble. 

The  glands  at  the  bottoms  of  these  sinuses  are  sometimes 
liable  to  take  on  inflammation  and  ulceration.  This  condition 
attends  phthisis  not  infrequently  ;  but  may  exist  independently 
of  this  or  any  other  apparent  systemic  affection. 

An  ulceration  in  one  or  both  of  these  sinuses  may  be  mis- 
taken for  laryngitis,  as  it  may  give  rise  to  irritation,  pain, 
hoarseness,  cough,  and  purulent  expectoration.  A  case  of  sup- 
posed chronic  laryngitis,  which  had  gone  the  rounds  of  several 
large  hospitals  in  Great  Britain  and  the  United  States  during 
eighteen  years,  and  had  been  ineifectually  treated,  though  occa- 
sionally relieved,  by  the  passage  into  the  larynx  of  a  sponge 
probang  loaded  with  a  solution  of  nitrate  of  silver,  was  found 
by  the  author,  on  laryngoscopie  inspection,  to  be  due  to  ulcera- 
tion in  one  of  these  sinuses,  and  was  effectually  cured  by  a  few 
local  applications  of  the  nitrate  of  silver,  made  under  guidance 
of  the  laryngoscope.  This  case,  on  account  of  the  view  it  af- 
forded of  the  entire  trachea,  and  several  rings  of  the  right 
bronchus,  was  exhibited  some  years  ago  at  Wilkesbarre  to  the 
members  of  the  Medical  Society  of  the  State  of  Pennsyh-ania. 


CHAPTER  XIV. 

DISEASES  OF    THE    NECK    AFFECTING     THE    DEEPER  TISSUES 
OF   THE   THROAT   SECONDARILY. 

There  are  a  number  of  affections  of  the  external  portion  of 
tlie  throat,  affecting  the  internal  structures  by  their  presence, 
and  the  inflammation  and  suppuration  to  which  thej  give  rise. 
Most  of  these  are  treated  of  in  surgical  treatises  under  the 
head  of  affections  of  the  neck,  but  some  of  them  are  very  lightly 
touched  upon. 

DIFFUSE  INFLAMMATION    OF    THE    TISSUES    OF    THE   NECK. 

We  sometimes  meet  with  a  diffuse  inflammation  of  the  tissues 
of  the  neck  which  cannot  be  referred  to  any  one  organ,  although 
the  submaxillary  and  the  cervical  glands  are  often  implicated. 
These  inflammations  appear  to  originate  in  the  cellular  tissue, 
and  become  dangerous  on  account  of  their  rapid  extension  to  the 
surrounding  and  deeper  structures.  The  connective  tissue  be- 
tween the  various  muscular  tissues  of  the  neck  becomes  destroy- 
ed, irregular  abscesses  form  which  point  externally  or  break  into 
the  trachea  or  oesophagus,  or  even  into  the  mouth,  the  pus  some- 
times following  a  circuitous  route  for  that  purpose.  In  one  case 
lately  seen  by  the  -  author  the  affection  began,  after  the  extrac- 
tion of  a  tooth,  by  an  inflammatory  swelling  of  the  submaxillary 
glands,  principally  upon  the  opposite  side,  closing  the  jaws  im- 
movably and  deforming  the  visage  to  a  marked  degree.  The 
lower  tissues  of  the  neck  were  not  affected  at  first.  In  a  few  days 
the  abscess  burst  into  the  mouth,  at  a  point  opposite  the  second 
molar  of  the  lower  jaw  on  the  side  of  the  greatest  enlargement, 
and  for  several  days  discharged  large  quantities  of  fetid  ichor- 
ous pus.  The  abscess  then  extended  beneath  the  digastric  and 
orao-hyoid  muscles  and  presented  externally  over  the  thyroid 
cartilage,  at  which  point  it  was  opened  by  incision,  giving  egress 


508  DISEASES    OF    THE    JSTECK. 

to  several  ounces  of  horribly  offensive  j)i^s,  in  which  were  clots 
of  blood  and  debris  of  dead  cellular  tissue.  As  soon  as  this 
counter-opening  was  made  the  discharge  by  the  mouth  ceased. 
The  parts  gradually  resumed  their  natural  appearance ;  but 
although  the  submaxillary  swellipgs  subsided  as  soon  as  the 
abscess  commenced  to  discharge  in  the  mouth,  the  rigidity  of  the 
jaws  did  not  subside  until  several  days  after  the  incision  of 
the  abscess  in  the  neck.  During  all  this  time  the  teetli  were 
slightly  separated  so  that  the  tip  of  the  tongue  could  be  passed 
between  them,  and  this  enabled  sufhcient  concentrated  licpiid 
nourishment  to  be  taken  to  keep  up  the  patient's  strength 
during  the  progress  of  the  abscess. 

Diffuse  abscesses  of  this  kind  require  to  be  carefully  watched, 
so  that  due  advantage  can  be  taken  of  any  disposition  they 
make  towards  coming  to  the  surface.  This  will  be  indicated 
by  the  erysipelatous  blush,  and  the  cedematous  condition  of  the 
external  parts.  Before  this  time  it  cannot  be  known  at  what 
point  the  pus  may  may  make  its  appearance,  and  it  would  there- 
fore be  injudicious  to  dissect  the  tissues  of  the  neck  in  order  to 
hunt  for  it.  But  as  soon  as  the  abscess  can  be  detected  exter- 
nally it  should  be  opened  by  incision,  to  prevent  the  burrowing 
of  the  pus  by  the  sides  of  the  trachea,  or  into  the  chest  behind 
the  sternum,  a  circumstance  which  would  be  almost  inevitably 
followed  by  penetration  of  the  pleura  and  the  discharge  into 
that  cavity  of  a  highly  offensive  and  irritative  material. 

Pirigoff  ^  recommends  the  division  of  the  tissues  of  the  neck 
where  tension  is  greatest,  for  antiphlogistic  purposes,  even  when 
the  position  of  the  abscess  cannot  be  ascertained. 

Discrimination  is  necessary  in  opening  abscesses  of  the  neck, 
especially  if  they  are  circumscribed.  The}^  are  sometimes  situ- 
ated over  large  arteries,  which  impart  to  them  their  pulsation,  so 
that  it  is  rendered  difficult  to  distinguish  an  abscess  from  an 
aneurism.  On  the  other  hand,  an  aneurism  may  be  mistaken  for 
an  abscess,  as  in  the  well-known  case  of  Liston,  who  unintention- 
ally opened  an  aneurism  in  the  neck  of  a  child,  Wardrop's  in- 
vestigations show  that  aneurisms  of  the  neck  are  most  likely  to 

^  Kriegchirurgie.     1864,  p.  113. 


TUMORS    OF    THE    NECK.  509 

appear  in  certain  sitnations.  Tims  an  aneurism  at  the  root  of  the 
carotid  artery  will  show  itself  iirst  in  the  small  triangle  between 
the  sternal  and  clavicular  portion  of  the  sterno-cleido-mastoid 
muscle ;  an  aneurism  of  the  innominate  artery  on  the  tracheal 
side  of  that  muscle  ;  and  an  aneurism  of  the  subclavian  at  the 
outer  side.  These  points  may  be  referred  to  in  a  case  of  doubt. 
Fortunately  these  cases  of  abscess  are  comparatively  infre- 
quent. They  are  often  fatal,  and  usually  by  pysemia  and  not 
by  suffocation.  The  bones  in  the  neighborhood  are  sometimes 
affected.  I  saw  one  case  after  recovery,  in  which  the  abscess 
broke  just  over  the  sternum,  the  adjacent  ends  of  the  clavicles 
having  apparently  undergone  inflammation  and  slight  loss  of 
substance.  The  lower  jaw,  the  hyoid  bone,  and  the  larynx 
Have  been  found  to  have  undergone  disease  in  consequence  of 
abscesses  of  the  kind  under  consideration. 

TUMOKS    OF    THE    NECK. 

Atheromatous,  fibrous,  sarcomatous,  enchondromatous,  cystic, 
and  other  tumors  of  the  neck  occur,  and  by  their  mechanical 
position  or  by  their  pressure  on  important  vessels  and  nerves 
produce  serious  secondary  affections,  referred  to  the  larynx, 
trachea,  pharynx,  and  oesophagus.  They  are  not  usually 
directly  dangerous  to  life  unless  they  acquire  a  great  bulk. 

In  many  of  these  cases  it  is  impossible  to  know  the  nature  of 
the  tumor  until  it  has  been  removed,  for  which  purpose  an  oper- 
ation is  sometimes  necessary  on  account  of  immediate  danger 
to  life.  As  a  rule,  however,  they  are  not  operated  upon  for  the 
mere  purpose  of  getting  rid  of  the  deformity  they  produce  ; 
for  it  is  impossible  to  know  beforehand  the  nature  of  the  at- 
tachments which  the  tumor  may  have  made,  and  which  may  im- 
plicate the  carotid  artery,  the  jugular  vein,  or  the  pneumogastric 
nerve. 

We  are  therefore  thrown  back  upon  general  treatment,  with 
leeching,  blistering,  and  the  rubbing  in  of  absorbent  ointments 
into  these  tumors.  Lymphatic  tumors  of  recent  formation  some- 
times subside  under  the  influence  of  treatment  of  this  kind  ;  but 
those  of  long  standing,  and  tumors  of  other  kinds,  are  not  very 
amenable  to  treatment. 


510  DISEASES    OE    THE    NECK. 

Electrolysis  has  been  suggested  as  affording  a  means  of  pro- 
ducing recession  or  absorption  of  these  tumors  ;  and  some  cases 
of  success  are  reported '  by  Mauduyt,  Duchenne,  Demarquay, 
and  Meyer.  In  three  cases  of  -atheromatous  tumor,  apparently 
of  the  same  nature  as  some  of  those  referred  to,  the  process  was 
faithfully  tried  by  the  author  for  an  extended  period  without 
success ;  and  one  case  was  placed  by  him,  after  failure  in  his 
own  hands,  under  the  care  of  a  physician  specially  skilled  in  the 
applications  of  electricity  to  medicine  and  surgery,  but  without 
a  more  successful  result. 

Tumors  in  the  mediastinum  produce  symptoms  affecting  the 
larynx,  trachea,  etc.  Tlius  they  produce  hoarseness ;  aphonia ; 
whistling  or  stridulous  inspiration;  expectoration,  sometimes 
sanguinolent ;  vomiting ;  and,  towards  the  last,  epistaxis. 

Operations  for  the  Extirpation  of  Tumors  of  the  Neck. 
— If  the  tumor  occupy  the  anterior  portion  of  the  neck,  a  vertical 
incision  is  usually  made  in  the  median  line  ;  but  if  it  be  in  the 
region  of  the  sterno-cleido-mastoid  muscle  or  beneath  it,  the  in- 
cision is  made  in  a  line  with  the  anterior  or  posterior  border  of 
that  muscle,  or  a  double  incision  is  practised  including  a  space 
equal  to  the  breadth  of  the  muscle,  as  the  case  may  be.  It  is 
only  under  unavoidable  circumstances  that  this  muscle  is  to  be 
cut,  and  therefore  the  external  incisions  are  made  so  as  to  admit 
of  working  beneath  it,  to  facilitate  which  the  muscle  is  relaxed 
by  bending  the  head  to  that  side.  If  its  division  cannot  be 
avoided,  it  should  not  be  cut  to  any  extent  greater  than  is  abso- 
lutely necessary.  As  a  rule,  bleeding  vessels  are  scruj^ulously 
ligated,  and  careful  dissection  made  to  the  sheath  of  tissue  in 
which  the  tumor  is  embedded,  when  an  attempt  is  made  to  de- 
tach it  by  the  fingers  alone  without  the  aid  of  any  cutting  instru- 
ment. When  densely  adherent,  its  connections  are  broken  down 
as  far  as  may  be  deemed  safe,  and  the  root  of  the  mass  is  encir- 
cled by  a  very  stout  double  or  triple  ligature  so  as  to  compress 
any  vessels  which  it  may  contain;  and  the  division  is  made  in 
front  of  the  ligature.  If  the  operation  present  complications  of 
hemorrhage  and  the  tumor  is  to  be  removed  at  all  hazards,  it 

'  Moritz  Meyer ;  Electricity  in  Practical  Medicine.  Hammond's  Translation. 
N.  Y.,  1869.     p.  480. 


TUMORS    OF    THE    Is^ECK. 


511 


should  be  removed  from  its  cardiac  surface  first,  in  order  to  avoid 
the  frequent  ligation  of  vessels  from  the  same  trunk.  Care  must 
be  taken  to  see  whether  the  tumors  have 

Fio-.  133. 

formed  attachments  with  the  sheath  of 
the  great  vessels,  lest  they  be  incautiously 
wounded ;  and  in  examinations  to  deter- 
mine this  point  the  natural  relation  of  parts 
must  not  be  disturbed  too  much,  else,  as  I 
have  witnessed  in  an  operation  for  the  re- 
moval of  a  cystic  tumor  from  the  neck  of 
an  infant,  unnecessary  dangers  may  be 
encountered;  in  this  instance  the  internal 
jugular  vein  was  drawn  out  and  lengthened 
so  as  to  look  like  the  wall  of  the  cyst,  and, 
had  it  not  been  for  the  prompt  attention  of 
a  skilled  assistant,  the  vein  might  possibly 
have  been  wounded. 

After  removal  of  the  tumor  the  upper 
portion  of  the  external  wound  is  united  by 
suture,  and  a  pledget  of  linen  inserted  in 
the  lower  portion  to  prevent  union  and 
permit  drainage.  A  cold-water  compress, 
or  an  oiled  rag,  as  may  be  preferred,  with 
lint  to  absorb  the  secretions,  secured  by 
bandage,  completes  the  dressing. 

Severe  inflammation  is  liable  to  occur 
after  extensive  operations  in  the  region  of 
the  great  vessels  of  the  neck ;  and  this  is  to 
be  met  by  the  usual  antiphlogistic  treat- 
ment. 

Fig.  133  is  introduced  to  illustrate  an 
admirable  instrument  recently  devised  by 
Dr.  Addinell  Hewson,  of  the  Pennsylvania 
Hospital,  for  seizing  and  twisting  bleeding 
arteries.  It  can  be  manipulated  with  a 
single  hand,  and  could  be  very  advanta-  ^ 
geously  used  in  controlling  the  hemorrhage 
that  sometimes  attends  operations  in  the  neck 


Addinell  Hewson's  Tor- 
sion Forceps. 


512  DISEASES    OF   THE    NECK. 


MUMPS. 


Mumps  is  the  name  given  to  a  peculiar  contagious  inflamma- 
tory affection  of  the  parotid  gland  and  the  surrounding  tissues. 
It  occurs  chiefly  in  young  male  adults,  especially  when  crowded 
together  in  colleges,  armies,  jails,  etc. ;  but  it  may  affect  women 
and  children  also.  It  is  sometimes  epidemic.  The  disease, 
whatever  its  nature  may  be,  is  liable  to  be  continued,  as  it  were, 
in  the  testicles  or  the  mammse,  its  extension  to  these  organs, 
when  occurring,  being  part  of  the  real  progress  of  the  disease 
rather  than  a  mere  metastasis. 

The  first  symptom  of  the  affection  is  usually  pain  and  stiffness 
at  the  angle  of  the  jaws,  followed  by  swelling  behind  and  below 
the  ears,  sometimes  on  one  side  only,  more  frequently  upon 
both.  Deglutition  becomes  painful,  and  there  is  difliculty  or 
inability  to  open  the  mouth.  Sore-throat  is  often  complained  of, 
and  ear-ache  also  not  infrequently.  There  is  more  or  less  fever, 
with  the  attendant  symptoms  of  that  condition  for  two  or  three 
days,  when  it  gradually  declines.  Yery  often,  as  the  fever  de- 
clines, the  swelling  over  the  parotid  region  subsides,  and  is  fol- 
lowed by  swelling  of  the  testicles  in  the  male  or  the  mammae  of 
the  female,  one  or  both  glands  being  affected.  There  are  some- 
times symptoms  of  a  similar  transference  of  the  morbific  influ- 
ence to  internal  organs.  Sometimes  it  takes  place  to  the  brain, 
threatening  collapse,  meningitis,  or  even  mania ;  and  this  cere- 
bral disturbance  sometimes  terminates  fatally.  The  parotid 
gland  rarely  suppurates  ;  but  the  affection  is  said  to  terminate 
in  this  manner  occasionally. 

The  treatment  of  mumps  is  mildly  or  actively  antiphlogistic, 
according  to  the  vigor  of  the  patient  and  the  character  of  the 
case.  I  have  found  good  results  from  the  hot-air  or  sweat  bath, 
conducted  in  the  patient's  room  by  means  of  burning  alcoliol 
beneath  a  chair  upon  which  the  patient  sits  enveloped  in  a 
blanket.  Warm  applications  are  kept  to  the  inflamed  part ;  for 
which  purpose  a  wad  of  soft  cotton,  wrung  out  of  boiling  water, 
and  then  placed  in  a  bag  of  oiled  silk,  is  one  of  the  nicest  appli- 
cations I  know  of.  Cold  applications  are  to  be  avoided,  lest 
they  repel  the  disease  to  the  testicle.     A  slight  saline  cathartic 


BURSAL    TUMOES    OF    THE    THYEO-HYOID    EEGION.      513 

is  sometimes  indicated,  but  active  treatment  is  not  often  called 
for.  If  the  testicle  becomes  involved,  v^arm  fomentations  are 
required,  with  confinement  in  bed,  if  the  patient  has  been  per- 
mitted to  sit  up. 

If  the  brain  becomes  involved,  stimulants  will  be  called  for 
in  a  state  of  collapse  ;  the  lancet,  cold  to  the  head,  purgatives, 
and  counter-irritants  at  a  distance,  in  mania. 

Permanent  injury  to  the  gland,  or  to  the  constitution,  some- 
times follows  this  affection.  Blistering,  the  use  of  mercurial 
and  iodized  ointments,  are  recommended  for  the  enlarged  gland, 
and  tonic  and  alterant  remedies  for  the  constitution. 

A  swelling  of  the  lymphatic  glands  in  the  region  of  the  pa- 
rotid, sometimes,  perhaps,  of  the  parotid  itself,  occurs  not  in- 
frequently in  connection  with  abscess  of  the  pharynx,  as  already 
mentioned  in  a  former  portion  of  this  volume;  and  a  case  of 
pharyngeal  abscess  may  therefore  be  mistaken  for  mumps ;  and 
a  similar  condition  sometimes  occurs  in  connection  with  adyna- 
mic pneumonitis. 

BURSAL   TUMOKS    OF    TnE    TnYEO-HYOID    KEGION, 

There  are  three  bursse  in  the  thyro-hyoid  region,  which  oc- 
casionally become  the  origin  of  cystic  tumors.  One  of  these 
occurs  in  front  of  the  thyroid  cartilage,  and  is  known  as  the 
ante-thyroid  bursa  ;  it  is  subcutaneous.  Another  occurs  below 
the  hyoid  bone,  and  is  known  as  the  infra-hyoid  bursa.  It  is 
occasionally  multiple.  The  third  bursa  is  found  in  the  structure 
of  the  root  of  the  tongue,  and  is  known  as  the  supra-hyoid  bur- 
sa ;  it  is  situated  on  the  upper  border  of  the  hyoid  bone,  be- 
tween the  posterior  insertions  of  the  genio-hyoid  and  genio- 
glossal muscles  ;  it  appears  to  be  an  abnormal  bursa,  met  with 
only  occasionally.  These  bursas  are  liable  to  inflammation, 
serous  and  viscid  accumulations,  and  the  diseases  of  bursce  in 
other  regions  of  the  body ;  the  infra-hyoid  bursa  being  affected 
the  most  frequently,  and  the  supra-hyoid  bursa  the  least  fre- 
quently. 

Cysts  of  these  bursas,  technically  known  as  hygromata,  occur 

not  infrequently,  and  may  attain  sufficient   size   to  interfere 
33 


514  DISEASES    OF   THE    NECK. 

with  deglutition,  articulation  and  respiration.  They  may  un- 
dergo spontaneous  absorption,  but  this  is  infrequent;  and,  v/hen 
large  enough  to  interfere  with  function,  they  require  operation. 
Troublesome  fistules  are  apt  to  remain  after  the  discharge  of 
one  of  these  cysts.  The  affection  is  supposed  to  originate  from 
mechanical  irritation  of  the  bursa ;  and  it  is  of  slow  progres- 
sion. The  diagnosis  of  such  cysts  rests  on  their  seat,  and  the 
result  of  puncture  with  the  exploring  needle.  Their  contents 
do  not  differ  from  those  of  other  cysts,  save  that  they  do  not 
contain  any  epithelial  elements,  the  presence  of  which  is  in- 
dicative of  glandular  origin,  and,  under  these  circumstances, 
referable  to  the  thyroid  gland. 

Incision,  excision,  and  extirpation  of  these  cysts  have  been 
practised  ;  the  first  two  operations  are  not  often  successful ;  and 
extirpation,  complete  or  partial,  seems  to  be  followed  almost  in- 
evitably by  a  fistule,  which  is  hard  of  cnre.  Puncture  and  the 
injection  of  iodine  after  discharge  of  the  cyst  seems  to  offer  the 
best  chance  of  success.  For  further  details,  and  the  records  of 
a  number  of  interesting  cases,  the  reader  is  referred  to  the  clas- 
sical work  of  Giirlt.* 

AFFECTIONS    OF   THE    THYKOID    GLAND. 

The  normal  thyroid  gland  is  of  comparatively  small  size,  and 
is  seldom  the  seat  of  surgical  injury.  It  is  subject  to  disease, 
however,  such  as  inflammation  and  the  formation  of  abscess; 
but  the  most  frequent  affection  by  far  is  either  hypei-trophy, 
or  the  development  of  cystic  tumors  in  its  interior,  or  upon 
its  exterior.  These  affections  occur  in  females  much  more  fre- 
quently than  in  males,  possibly  on  account  of  some  sympathetic 
relation  between  the  gland  and  the  uterus.  The  thyroid  gland 
of  some  individuals  often  swells  during  menstruation  to  a  per- 
ceptible degree,  slight  though  it  may  be.  A  similar  effect  fre- 
quently follows  impregnation ;  and  in  olden  times,  the  size  of 
the  neck  was  measured  as  one  of  the  tests  of  virginity.  Certain 
forms  of  enlargement  of  the  thyroid  gland  increase  very  much 
in  size  during  each  successive  pregnancy  or  lactation,  and  re- 
tain the  enlargement  acquired  at  this  period. 

*  Ueber  die  Cystengescliwulste  des  Halses.  Berlin,  1855. 


AFFECTIOlSrS    OF   THE   THTEOID    GLAISTD.  515 

This  clironic  enlargement  of  the  thyroid  gland  is  termed 
goitre  or  bronchocele.  It  frequently  exists  endemically,  in  the 
valleys  of  mountainous  districts  especially  ;  being  so  universal 
in  some  localities  that  immunity  from  the  affection  is  regarded 
by  the  people  as  a  species  of  deformity,  or  an  arrest  of  develop- 
ment. Straiio-ers  visitino;  these  reo;ions  and  remainine;  there 
for  an}^  length  of  time  sometimes  acquire  goitre,  which  usually 
disappears  spontaneously  on  removal  from  the  locality.  This 
has  been  noticed  not  infrequently  in  the  troops  of  Continental 
armies  when  sent  into  regions  where  goitre  prevails  ;  a  few 
weeks'  sojourn  being  sufficient  to  produce  such  an  enlargement 
of  the  gland  as  to  render  the  collar  of  the  uniform  coat  too 
tight  to  permit  the  due  23erformance  of  military  duty.  The  in- 
fantry, whose  resj)iratory  organs  are  impeded  in  action  by  the 
w^eight  of  the  knapsacks  they  have  to  carry,  suffer  more  than 
soldiers  in  other  branches  of  service,  whose  respiratory  organs 
are  less  taxed. 

Exertion  of  various  kinds,  chilling  of  the  exposed  throat,  and 
other  causes  of  similar  nature,  seem  to  favor  the  development 
of  goitre ;  but  the  real  cause  is  not  well  understood,  even  in 
those  localities  where  it  exists  endemically. 

In  certain  of  the  valleys  of  the  Alps  goitre  is  associated  with 
a  condition  approaching  to  idiocy,  and  which  is  called  cretin- 
ism. Some  recent  observations  have  detected  a  great  difference 
in  the  temperature  of  the  two  sides  of  the  valleys  where  the 
Cretins  reside ;  this  temperature  being  subject  to  certain  con- 
siderable fluctuations  ;  and  it  is  believed  that  this  may  have  a 
great  deal  to  do  with  the  development  of  goitre,  in  consequence 
of  its  influence  on  the  circulatory  system. 

A  peculiar  variety  of  goitre  is  termed  exophthalmic  goitre, 
on  account  of  the  abnormal  prominence  of  the  eyeballs  which 
accompanies  it;  a  prominence  sometimes  amounting  to  protru- 
sion, and  due  to  an  accumulation  of  fatty  products  behind  the 
eyeball,  or  to  serous  infiltration  of  the  connective  tissue  of  the 
orbit.  It  is  also  accompanied  with  dilatation  and  palpitation  of 
the  heart,  the  impulses  of  which  are  over  one  hundred  in  a 
minute;  and  sometimes  exceed  this  by  twenty  beats,  and  even 
more,  under  the  influence  of   emotion  and   physical  exercise. 


516  DISEASES    OF   THE    NECK. 

Tliere  is  often  a  systolic  murmur  from  f niictioiial  Tal\n.ilar 
derangement  of  the  left  side  of  the  heart.  It  is  sometimes  an 
accompaniment  of  anaemia,  bnt  also  exists  with  plethora,  and  is 
encountered  almost  entirely  in  young  adult  females.  It  was 
first  properly  described  by  Prof.  Graves,  of  Dublin,  and  is 
known  as  Graves'  disease.  It  is  also  known  as  Basedow's  dis- 
ease, from  the  attention  called  to  it  by  a  German  physician  of 
that  name.  The  thyroid  gland  swells  in  its  entire  extent  into 
an  easily  compressible  tumor  of  large  size,  usually,  and  is  ac- 
companied by  a  systolic  thrill  of  the  superior  thyroid  artery, 
which  is  very  sensible  on  delicate  manipulation  of  the  tumor. 
The  pulsation  is  often  perceptible  to  the  patient,  and  is  at- 
tended with  throbbing  of  the  carotids  and  with  a  hammering 
or  singing  noise  in  the  ears.  When  the  patient  maintains  a 
recumbent  position,  these  symptoms  are  less  manifest.  The 
eyes  are  usually  in  constant  motion ;  and  in  marked  cases,  the 
protrusion  of  these  organs  is  so  great  as  to  prevent  closure  of 
the  lids  even  in  sleep.  Sometimes  there  is  paresis  of  the  upper 
lid,  and  sometimes  there  is  strabismus.  The  sight  suffers.  In- 
flammation of  the  cornea  sometimes  supervenes  in  consequence 
of  its  constant  exposure.  The  nutrition  of  the  system  is  im- 
paired, and  the  patient  sometimes  dies,  in  the  course  of  several 
years,  from  marasmus. 

Dr.  Graves  considers  the  affection  a  neurosis  of  the  sympa- 
thetic nerve.  Prof.  Stromeyer'  considers  the  exophthalmus  an 
additional  evidence  of  the  nervous  nature  of  the  affection,  from 
the  fact  that  he  has  observed  a  similar  condition,  indej)endent 
of  any  affection  of  the  thyroid  gland,  in  the  habitual  spasm  of 
the  sterno-cleido-mastoid  muscle  ;  in  which,  however,  the  pro- 
trusion of  the  eyeball  is  confined  to  the  side  of  the  muscle  affect- 
ed, occurring  only  when  its  contractions  are  excited  by  an  erect 
position  of  the  head,  or  under  the  influencte  of  emotion.  This 
habitual  spasm  of  the  sterno-cleido-mastoid  muscle,  Sti'omeyer 
says,  is  considered  by  every  one  as  a  neurosis ;  and  the  fleeting 
exophthalmus  which  exists  in  connection  with  it  appears  to  be 
dependent  uj)on  spasm  of  the  oblique  muscle  of  the  eyeball,  and 
of  the  levator  palpebrre. 

1  Op.  citat.,  p.  389. 


AFFECTIONS    OF   THE   THTEOID    GLAND.  517 

A  marked  case  of  exoplithalmic  goitre,  attended  with  acute 
mania,  was  placed  under  the  care  of  the  author  a  few  years  ago. 
The  contortions  of  the  patient,  when  under  the  influence  of  the 
cerebral  excitement,  were  extreme ;  and  implicated  the  entire 
body,  so  that  it  was  difficult  to  keep  the  patient  covered  in  a 
state  of  decency.  Being  unable  at  the  time  to  give  the  case 
the  attention  it  demanded,  I  enlisted  the  ser^nces  of  Dr.  Collins, 
of  Philadelphia,  who  resided  a  short  distance  from  the  patient, 
and  who  paid  her  frequent  visits.  His  great  interest  in  the 
case,  unremitted  during  a  series  of  two  or  three  years,  led  to 
the  confirmation  of  the  theory  of  neurosis ;  and  under  the  in- 
fluence of  nervous  stimulants,  ferruginous  tonics,  and  cold  ap- 
plications externally,  he  was  finally  enabled  to  cure  his  patient, 
who  was  exceedingly  grateful  for  his  attention.  He  often 
speaks  to  me  of  "  grateful  Maggie." 

Goitre,  as  already  mentioned,  occurs  chiefly  in  females  ;  but 
it  also  occurs  in  males.  It  may  be  present  as  a  congenital  affec- 
tion, but  more  frequently  makes  its  a^^pearance  about  the  period 
of  puberty  or  early  adolescence.  Sometimes  it  occurs  in  several 
members  of  the  same  family,  and  seems,  at  times,  to  be  acquired 
in  consequence  of  a  hereditary  proclivity.  The  size  of  the 
tumor  may  vary  from  a  mere  fulness  of  the  gland  to  a  bulk  as 
large  as  an  adult  head.  A  not  infrequent  size  is  that  of  the  head 
of  an  infant.  When  very  large  it  usually  drags  the  skin  of  the 
neck  down  and  may  project  over  the  chest.  I  have  seen  an 
instance  where  it  projected  several  inches  over  the  chest,  looking, 
in  form,  not  unlike  a  large  gourd  of  the  squash  or  pumpkin 
species.  The  enlargement  may  be  altogether  in  fi-ont ;  or  it  may 
extend  beneath  the  sterno-cleido-mastoid  muscles,  or  behind  the 
sternum.  In  the  latter  cases  there  is  a  good  deal  of  pressure 
exercised  uj)on  the  trachea,  giving  rise  to  symptoms  of  a  very 
distressing  character,  resembling  those  of  asthma,  and  produc- 
tive, ultimately,  of  pulmonary  emphysema.  In  the  variety 
known  as  post-sternal  goitre,  the  trachea  is  compressed  into  the 
form  of  a  prismatic  cylinder,  or  an  elongated  ovbI,  the  larger 
diameter  of  which  may  be  in  the  lateral  or  in  the  antero-poste- 
rior  direction.  The  enlargement  is  usually  very  slow,  consum- 
ing naany  months  or  years  in  its  progress.     Sometimes  the  affec- 


518  DISEASES    OF   THE    NECK. 

tion  remains  at  a  stand-still  for  a  number  of  years,  and  then 
gradually  increases  in  size.  As  a  rule  there  is  no  pain  in  a 
tumor  of  this  kind,  the  suffering  being  produced  by  pressure 
upon  the  windpipe  and  the  large  vessels,  finally  culminating  in 
attacks  of  suffocation,  spasmodic  cough,  with  inability  to  main- 
tain the  recumbent  posture  ;  producing  a  general  drain  upon 
the  system,  accompanied  with  cedema  of  the  limbs,  trunk,  and 
larynx. 

The  goitre  may  affect  both  lobes  of  the  thyi'oid  gland,  or  only 
one  of  them ;  or  may  be  confined  to  the  isthmus  ;  or  to  a  third  or 
supplementary  lobe  which  sometimes  exists ;  or  may  affect  one 
lateral  lobe,  and  either  the  isthmus  or  the  supplementary  lobe. 

The  contents  of  the  tumor  varies  at  different  stages.  At  first 
it  is  soft  and  elastic  to  the  touch,  and  withoitt  any  extensive 
attachments  to  the  surrounding  tissues.  It  is  then,  in  all  jDrob- 
ability,  a  mere  hypertrophy  or  hyperplasia  of  the  original  struc- 
ture ;  and  when  in  this  condition  is  often  amenable  to  the  influ- 
ence of  remedial  agents.  After  a  while  irregularities  or  nodo- 
sities are  produced  upon  its  surface,  usually  indicative  of  some 
metamorphosis  of  tissue,  rendering  the  prognosis  of  cu^-e  much 
more  doubtful.  The  changes  which  have  been  noticed  in  en- 
largements of  the  thyroid  gland  are  inflammation,  the  formation 
of  cysts,  and  the  flbro-sarcomatous  and  cancerous  degeneration, 
principally  of  the  encephaloid  variety.  When  inflammation  is 
going  on,  the  parts  become  hot,  and  firmer  to  the  touch.  This 
inflammation  is  sometimes  salutary  and  leads  to  a  spontaneous 
dissolution  of  the  tumor,  a  knowledge  of  which  fact  has  sug- 
gested a  method  of  treatment  by  the  artiflcial  induction  of  in- 
flammation. When  this  does  not  occur,  the  inflammation  may 
result  in  abscess,  or  in  the  formation  of  permanent  fibrinous 
deposits  ;  or  it  may  extend  to  the  larynx  and  trachea,  endan- 
gering a  fatal  result,  either  by  its  action  upon  these  structures, 
or  by  pysemia.  The  fibrinous  deposits  of  the  inflammatory  pro- 
cess may  subsequently  undergo  the  fatty,  or  the  calcareous  de- 
generation. 

The  formation  of  cysts  in  the  tissue  of  a  goitre  is  favored  by 
the  anatomical  structure  of  the  gland  itself,  the  cells  of  which 
become  distended  by  an  accumulation  of  their  natural  contents. 


AFFECTIOlSrS    OF   THE    THYEOID    GLAISTD.  519 

the  cell  originallj  affected  enlarging  at  the  expense  of  its  neigh- 
bors, the  remaining  glandular  structure  undergoing  atrophy 
from  pressure.  Usually  one  or  a  few  cysts  enlarge  in  this  way 
to  a  great  size,  but  sometimes  numerous  cysts  enlarge  to  sizes 
varying  from  that  of  a  ]3ea  to  that  of  a  plum.  In  this  way  the 
encysted  form  of  goitre  is  produced,  a  form  recognized  usually 
by  the  sense  of  fluctuation,  or  by  the  withdrawal  of  a  portion 
of  its  contents  upon  the  groove  of  the  exploring  needle. 

When  the  cysts  are  small  their  contents  are  viscid,  but  when 
large  they  contain  serum,  or  serum  and  blood,  or  coagulated 
blood,  or  the  debris  of  fibrous  tissue.  The  cysts  are  usually 
complete,  but  sometimes  a  portion  of  their  wall  is  composed  of 
the  gland  tissue  itself.  Cystic  goitres  may  attain  a  very  great 
size,  and  have  been  known  to  contain  more  than  a  pint  of  fluid. 
Large  cysts  are  not  apt  to  undergo  degeneration,  but  the  walls 
of  the  smaller  ones  sometimes  become  calcified. 

A  peculiar  form  of  cystic  goitre  in  which  new  glandular 
tissue,  exactly  analogous  to  the  embryonic  tissue  of  the  thyroid 
gland,  becomes  developed  in  the  cavity  of  the  cyst,  has  been 
described  by  Prof.  Stromeyer,  and  by  him  designated  as  paren- 
chymatous cystic  goitre.'  This  tissue  is  very  vascular  and  very 
gelatinous,  so  that  it  can  be  scoopied  out  with  the  finger.  It 
presents  a  deceptive  sense  of  fiuctuation  when  examined  exter- 
nall}^,  and  in  this  way  may  be  readily  mistaken  for  the  ordinary 
cystic  goitre  with  fluid  contents.  Its  diagnosis,  however,  cannot 
be  always  ascertained  with  certainty,  except  during  the  course 
of  an  operation. 

Goitre  of  Pregnancy.— It  has  already  been  remarked  that 
in  certain  females  an  hypertrophy  of  the  thyroid  gland  occurs 
during  the  progress  of  pregnancy.  The  enlargement  occasion- 
ally becomes  immense  and  proves  eventually  fatal.  Two  cases  of 
this  kind  reported  by  Prof.  Guillot '  will  illustrate  the  subject, 
and  also  illustrate  some  of  the  most  serious  symptoms  j)roduced 
by  goitre,  as  well  as  sonje  important  points  in  its  pathology. 

"  1.  A  lady,  ^t.  30,  under  the  care  of  M.  Agouard,  Jr.,  in  easy 
circumstances,  of  good  constitution,  never  having  been  sick,  born 

'  De  rhypertrophie  de  la  glande  thyroide  des  femmes  enceintes.  Arc/lives 
Generales  de  Medecine.     Novembre,  1860. 


520  DISEASES    OF   THE    NECK. 

and  residing  distant  from  localities  favorable  to  tlie  development 
of  goitre,  was  surprised  to  see  during  her  first  pregnancy  that 
the  anterior  region  of  her  neck  began  to  swell  gradually  ;  but 
as  she  did  not  suffer  at  all,  and  as  the  progress  of  the  tumefac- 
tion was  slow,  she  paid  hardly  any  attention  to  it.  The  menses 
returned  after  this  pregnancy. 

"  Eighteen  months  afterw^ards,  in  1855,  she  gave  birth  to  ano- 
ther infant ;  the  accouchement  was  favorable  ;  she  nourished  her 
infant.  During  this  pregnancy  the  tumor  of  the  neck  had  aug- 
mented anew  and  became  troublesome ;  at  fourteen  months  she 
ceased  to  nurse  her  infant.  The  menses,  which  had  reappeared 
for  several  months,  continued  to  be  regular.  The  tumor,  which 
increased  in  size  slowly,  interfered  with  the  movements  of  the 
neck,  and  respiration  often  became  laborious.  Pains  radiating 
fi'om  the  neck  as  far  as  to  the  precordial  region,  accompanied 
by  facial  neuralgia,  palpitations  and  vomitings,  tormented  the 
patient  suddenly.  Syncopes  preceded  by  vertigo,  followed  by 
intermittent  asthma  and  suffocative  paroxysms,  gave  great 
anxiety  to  the  physician  and  terrified  the  patient.  The  timbre 
of  the  voice  became  enfeebled  des]3ite  the  excellent  condition 
of  the  constitution. 

"  I  saw  the  patient  in  1858  with  M.  Trousseau ;  I  found  hemp 
and  about,  without  presenting,  at  the  first  aspect,  any  appearance 
of  suffering.  The  intelligence  was  clear.  The  fatigue  caused  by 
conversation,  and  the  enf  eeblement  of  the  timbre  of  the  voice, 
were  evident ;  nevertheless  the  lady  made  me  perfectly  fami- 
liar with  the  nature  of  the  phenomena  she  experienced. 

"  The  tumor,  whose  diameter  might  have  been  two  decimetres 
on  both  sides,  was  smooth  and  covered  by  perfectly  healthy 
integument,  except  a  few  rare  vesicles  appearing  upon  the  skin. 
It  was  divided  into  two  lobes,  whose  separation  was  but  little 
distinct ;  its  consistence  was  that  of  a  rounded  lipoma  without 
nodulation.  On  compressing  it  there  was  produced  a  great 
difficulty  of  respiration,  as  well  as  dizziness.  The  only  lesion 
I  could  discover  was  the  hypertrophy  of  the  thyroid  body,  and 
the  only  accidents  which  I  could  detect  as  liable  to  occur,  not 
doubtful.  It  was  agreed  with  M.  Augouard  and  M.  Trousseau, 
that  in  case  of  absolute  necessity  and  of  imminent  suffocation, 


AFFECTIONS    OF   THE    THYROID    GLAND.  521 

the  operation  of  laiyngotomy  might  be  practised  despite  the 
imcertaiuty  of  the  result  which  might  follow. 

"  This  operation  was  performed  December  19,  1858,  some 
days  after  the  consultation  with  Messrs.  Augonard  and  Trous- 
seau. During  the  night  M.  Richet  was  called  in  great  haste 
bj  the  attending  physician  and  by  the  family,  and  he  found  the 
patient  almost  asphyxiated.  Despite  great  difficulties,  the 
operation  was  made  rapidly,  and  was  followed  by  a  result  at 
first  f  avoidable ;  the  asphyxia  disappeared  and  the  patient  was  re- 
lieved ;  but  on  the  21st  of  December  she  died.  An  autopsy  was 
not  permitted. 

"  II.  A  3"oung  woman  about  29  years  of  age,  born  at  Paris,  of 
good  appearance,  not  scrofulous,  menstruated  regularly  up  to 
her  last  pregnancy,  following  which,  the  menses  again  appeared 
regularly.  She  perceived  that  after  her  first  pregnancy,  dating 
four  years  back,  her  neck  had  become  larger  than  usual.  She 
paid  little  attention  to  this  phenomenon,  which  did  not  change 
until  her  second  pregnancy,  that  is  to  say,  for  about  a  year  and 
a  half.     She  was  coniined  19  months  ago. 

"This  young  woman  entered  the  ISTecker  Hospital,  and  no 
other  lesion  could  be  detected  in  her  except  the  one  mentioned. 
She  presented,  at  the  anterior  part  of  the  neck,  a  voluminous 
tumor,  of  a  circumference  of  about  30  centimetres,  covered  by 
healthy  skin,  movable,  and  extending  from  the  thyroid  cartilage 
as  far  as  the  sternum  ;  it  interfered  with  the  movements  of  the 
neck,  and  prevented  the  dorsal  decubitus.  She  was  subject  to 
frontal  neuralgia,  and  had  attacks  of  asthma.  Respiration  was 
difficult,  slow,  and  whistling  during  inspii-ation  and  expiration. 
The  voice  was  not  altered  in  timbre,  but  it  was  tremulous  and 
painful.  This  woman  .said  that  all  these  phenomena  had  been 
produced  slowly,  but  had  increased  constantly  in  intensity.  She 
referred  their  origin  distinctly  to  her  first  pregnancy,  and  their 
new  progress  to  her  second  gestation.  She  was  annoyed  by  her 
clothing,  and  had  an  increasing  difficulty  in  walking,  in  muscular 
effort,  and  even  in  resting  in  the  recumbent  position.  Her  suf- 
ferings were  becoming  exasperated  ;  from  time  to  time,  she  felt 
a  disposition  to  sleep  ;  deep-seated  pains  existed  in  the  chest,  and 
palpitations ;  suffocation  became  then  imminent.     These  sorts  of 


522  DISEASES    OF    THE    NECK. 

attacks,  at  first  slight  and  far  apart,  became  more  frequent  and 
severe,  and  caused  the  patient  a  great  deal  of  trouble. 

"  All  these  occurrences  were  reproduced  at  the  hospital,  al- 
though the  patient  could  rise  and  walk  during  each  moment  of 
feeling  well.  They  became  more  grave,  and  about  eight  days 
after  seeing  her  for  the  first  time,  Prof.  Guillot  thought  that 
she  would  expire.  During  each  access  of  suffocation  the  patient 
complained  of  great  pain  from  the  middle  region  of  the  sides 
of  the  neck  down  to  the  deepest  parts  of  the  chest ;  and  com- 
jilained  more  of  this  pain  than  of  the  difificulty  of  respiration. 
A  continued  drowsiness  accompanied  the  asphyxia  which 
succeeded  one  of  these  attacks,  and  which  killed  the  pa- 
tient. 

"Prof.  G.  was  ignorant  of  the  treatment  to  which  this  patient 
was  subjected  before  her  admission  into  the  hospital.  He  per- 
formed a  venesection.  She  took  pediluvia  and  received  some 
purgative  lavements,  and  towards  the  end  of  her  life  all  her 
limbs  were  covered  with  sinapisms. 

"  Mr.  Lenoir,  who  saw  the  patient,  did  not  deem  it  operable. 

"  The  examination  of  the  cadaver  did  not  reveal  any  other 
lesion  than  the  one  spoken  of.  The  thyroid  body  had  acquired 
very  nearly  the  volume  of  a  human  brain,  including  the  two 
pneumogastric  nerves,  the  two  carotid  arteries  and  the  trachea. 
This  mass  was  divided  in  three  lobes,  of  which  two  only  had 
appeared  at  the  exterior,  although  the  middle  lobe  was  situated 
beween  them  ;  but  it  was  smaller  than  the  others.  Behind  the 
tumor,  the  trachea  was  found  flattened,  its  anterior  posterior 
diameter  not  exceeding  3  millimetres,  its  bilateral  diameter  be- 
ing 2  centimetres.  This  flattening  commenced  below  the 
larynx,  and  was  prolonged  in  nearly  the  entire  length  of  the 
canal,  without  there  being  the  slightest  trace  of  any  other  lesion 
upon  the  mucous  membrane.  IJpon  the  sides  of  the  neck,  the 
two  carotids  and  the  pneumogastric  nerves  had  evidently  been 
compressed  upon  the  apophyses  of  the  vertebrae  by  the  weight 
of  the  lobes  of  the  tumor.  The  lungs  were  congested,  and  the 
bronchi  fllled  with  frothy  material.  The  tissue  of  the  thyroid 
body,  similar  in  appearance  to  the  tissue  of  a  healthy  organ, 
did  not  differ  from  it  in  color,  in  density,  nor  in  volume,  but 


AFFECTIONS    OF   THE    THTEOID    GLAND.  523 

in  a  series  of  details  which  were  made  apparent  by  an  attentive 
analysis. 

"  In  the  norjnal  state  the  thyroid  gland  is  formed  by  a  skeleton 
of  slightly  dense  hbrous  tissue,  by  which  are  formed  a  multi- 
plied series  of  little  spaces  of  a  diameter  equivalent  to  one  or 
two  millimetres.  The  interior  surface  of  these  little  spaces  or 
cells  is  covered  by  a  very  fine  epithelium.  The  interior  of  each 
one  of  these  contains  an  alkaline  albuminous  liquid,  in  which 
swim  vesicules,  globules,  cellules  or  molecules,  perfectly  round- 
ed, nucleated,  or  non-nucleated.  The  consistence  of  the  tumor 
under  consideration  was  more  firm  than  in  the  ordinary  con- 
dition, being  due  to  an  abundance  of  fibrous  tissue,  forming 
throughout  the  tumor  large,  thick,  and  multiple  partitions, 
although  their  density  was  not  as  great  as  that  of  ordinary 
fibrous  tissue.  The  character  of  the  tissue  of  these  partitions 
was  much  that  which  is  attributed  to  fibrous  tissue ;  it  was  re- 
presented by  a  series  of  rectilinear  elements,  some  of  which 
still  retained  the  relief  of  a  nucleolus.  These  elements,  felted 
together  by  an  intimate  commingling,  formed  the  partitions 
and  the  contours  of  the  spaces,  whose  diameters  were  otherwise 
more  considerable  than  ordinary.  There  were  spaces,  in  fact, 
whose  breadth  was  in  several  points  more  than  three  centi- 
metres, and  in  other  points  equal  to  three  or  two  millimetres, 
representing  a  series  of  intermediates,  varying  from  the  normal 
diameter  to  that  just  indicated.  The  walls  of  these  spaces  were 
whitish  and  j)earlish ;  and  although  they  were  not  very  dense, 
they  were  in  reality  composed  of  fibrous  tissue  whose  characters 
the  microscope  revealed  very  clearly.  The  surface  of  the  little 
spaces  formed  by  these  envelopes  of  fibrous  tissue  appeared  to 
be  covered  with  epithelium,  evidences  of  which  were  discover- 
ed mixed  with  the  globules  contained  in  each  space.  But  the 
large  cavities .  which  discriminated  it  from  the  normal  state, 
did  not  contain  any  appearance  of  epithelial  cellules  ;  nothing 
else  was  encountered  but  a  series  of  transparent  granulations, 
spheroidal,  nucleated  or  non-nucleated,  such  as  are  ordinarily 
contained  in  the  normal  cellules  of  the  thyroid  body.  Except 
the  volume  produced  by  the  excessive  accumulation  of  the 
anatomic  elements  of  this  thyroid  body,  everything  about  it  then 


524  DISEASES    OF    THE    NECK. 

was  similar  to  that  whicii  is  observed  in  an  ordinary  thyroid 
body.  The  only  difference  was  characterized  by  the  absence  of 
epithelinm  in  the  cavities  most  modified  in  appearance. 

"  We  might  then  be  anthorized  to  consider  this  lesion  of  the 
thyroid  body  as  an  hypertrophy  of  the  fibrous  and  grannlons 
elements  which  constitute  this  organ." 

The  treatment  of  goitre  resolves  itself  into  constitutional  and 
local.  It  is  only  in  recent  cases,  and  in  those  of  comparatively 
small  size,  that  treatment  can  be  employed  with  a  fair  pros- 
pect of  success. 

Operations  of  Yarions  kinds  have  been  performed  for  the 
destruction  or  removal  of  a  goitrons  tumor ;  but  althongh  they 
have  often  proved  sncccssful,  they  are  not  to  be  resorted  to 
without  careful  consideration,  in  view  of  the  dangers  at- 
tending the  operation.  The  danger  arises  from  the  vascjular 
condition  of  the  gland  itself;  the.  nature  and  importance  of  its 
attachments,  which  may  involve  the  large  vessels  and  nerves  of 
the  neck ;  and  the  complications  which  may  arise  during  the 
course  of  the  after-treatment.  Many  cases  of  death  have  been 
produced  by  operations  upon  the  thyroid  gland  ;  some  of  them 
occurring  on  the  0]3erating-table.  For  this  reason,  all  surgeous 
approach  these  operations  hesitatingly;  while  some  surgeons, 
whose  authority  is  the  highest  in  the  estimation  of  their  pro- 
fessional brethren,  condemn  them  unhesitatingly. 

When  goitre  is  due  to  residence  in  a  certain  locality,  removal 
from  that  localitj^  would  be  indicated  as  the  first  step  towards  relief. 

The  liberal  use  of  iodide  of  potassium,  internally  and  ex- 
ternally, has  been  often  effective  in  cases  of  soft  consistence 
and  uncomplicated,  even  when  of  considerable  size.  Should, 
however,  the  internal  administration  of  this  remedy  interfere 
with  the  general  health,  it  must  be  suspended  for  a  time.  It 
has  been  intimated,  on  high  authority,  that  this  disturbance  of 
the  general  health  is  not  alone  due  to  the  remedy  itself,  but  in 
great  part  to  the  rapid  absorption  of  the  constituents  of  the 
diminishing  tumor.  If  catarrhal  inflammation  of  the  larynx 
and  trachea  exist,  this  must  be  combated  in  great  measure 
befoi'e  resorting  to  specific  treatment  for  the  goitre  itself,  inas- 


AFFECTIONS    OF    TIIE    THYEOID    GLAND.  525 

mncli  as  the  constant  movement  of  tlie  gland  in  the  acts  of 
couffhins  is  unfavorable  to  the  retrogression  of  the  tumor.  In 
these  cases  the  muriate  of  ammonia  is  indicated,  on  account  of 
its  favorable  effect  upon  inflammatory  conditions  of  the  air-pas- 
sages, as  well  as  for  its  value  in  the  absorption  of  hjpertrophied 
tissue.  Various  other  remedies  than  those  mentioned  have  been 
recommended  in  the  treatment  of  goitre  ;  but  most  of  them  have 
been  selected  empirically,  and  do  not  appear  to  have  given  as 
much  satisfaction  in  general  as  the  employment  of  the  iodide 
of  potassium,  or  the  muriate  of  ammonia. 

When  medicinal  treatment  fails  in  the  diminution  of  the  tumor, 
electricity  often  offers  a  fair  prospect  of  success.  Cases  are  on 
1,'ecord  of  successful  electric  and  electrolytic  treatment  by  va- 
rious authorities,  abroad  and  in  this  country.  Two  successful 
cases  of  this  kind  occurred  in  the  author's  practice ;  one  of 
several  years'  standing,  and  of  large  size,  in  a  young  man  who 
had  undergone  the  iodic  and  other  medicinal  treatment,  under  the 
care  of  competent  and  eminent  physicians,  for  three  or  four 
years.  Both  lobes  of  the  thyroid  were  enlarged,  one  more  than 
the  other.  Electrolytic  treatment  with  the  negative  pole  in- 
serted by  a  needle  electrode  into  the  substance  of  the  tumor, 
with  the  positive  pole  applied  outside  by  means  of  a  large 
sponge,  caused  the  absorption  of  this  tumor  in  a  few  weeks ; 
but  five  applications  being  necessary  for  the  purpose.  Four 
Bunsen  cells,  of  very  large  size,  containing  a  "gallon  of  very 
weak  solution  each,  were  used  in  this  case,  and  the  current  was 
passed  from  five  to  ten  minutes  at  a  time. 

The  other  case  was  that  of  a  young  lady  some  seventeen 
years  of  age,  with  a  goitre  of  very  moderate  size  and  of  soft 
consistence,  which  began  to  appear  some  two  or  three  years 
before,  while  the  individual  was  in  Switzerland  on  a  visit.  In 
this  instance,  fifteen  small  Smee  cells  were  nsed;  ten  applica- 
tions being  required  for  the  complete  disappearance  of  the  tu- 
mor, the  applications  being  made  twice  a  week  and  for  about 
ten  minutes  at  a  time.  In  neither  instance  was  the  pain  great; 
so'that  anaesthesia  was  not  requisite. 

In  one  other  case  of  immense  cystic  goitre,  some  little  favor- 
able result  followed  a  protracted  treatment  of  some  twenty  ap- 


526  DISEASES    OF   THE    NECK. 

plications,  from  a  Smee's  battery  of  from  ten  to  twenty,  and,  on 
one  or  two  occasions,  thirty  small  cells ;  the  nmnber  being  in- 
creased during  the  application  according  to  the  effects  upon  the 
patient.  Circumstances  over  which  the  author  had  no  control, 
prevented  the  continuance  of  the  treatment. 

In  still  another  instance,  a  patient  w'ith  a  goitre  the  size  of  a 
large  orange  was  being  treated  with  the  induced  current  for 
paralysis  of  one  vocal  cord.  During  this  treatment  the  goitre 
diminished  considerably  in  size,  and  finally  disappeared,  though 
the  lady  had  been  encumbered  with  it  for  ten  or  twelve  years. 

In  the  treatment  by  electrolysis,  there  was  always  a  gaseous 
swelling  produced  at  the  seat  of  puncture,  from  the  develop- 
ment of  hydrogen  gas ;  the  tissues  around  for  a  considerably 
distance  became  very  red,  and  presented  a  bruised  or  black 
and  blue  appearance,  as  from  a  blow  of  the  fist,  for  a  day  or  two 
after ;  and  a  little  eschar  was  formed  at  the  point  of  puncture. 
Occasionally  a  drop  or  two  of  blood  followed  the  withdrawal 
of  the  needle,  but  this  was  exceptional.  On  several  occasions 
vertigo,  and  on  one  occasion  syncope,  was  produced  during  the 
application.  No  internal  treatment  w^hatever  was  employed 
during  the  treatment  of  any  of  these  cases.  In  the  (;ase  of  the 
young  girl  alluded  to,  a  bag  of  small  shot  was  worn  upon  the 
tumor  for  several  hours  every  day,  in  order  to  favor  absorption 
by  equable  compression. 

In  the  recent  works  on  electricity,  many  cases  are  given  of 
the  cure  of  goitre  by  electricity ;  and  Dr.  Althaus  ^  expresses 
the  belief  that  all  cases  of  bronchocele,  however  large,  may  be 
cured  by  electrolysis,  if  the  treatment  be  persevered  in  for  a 
suflicient  time ;  the  cystic  variety  being  much  more  rapidly 
curable  with  it  than  the  solid. 

When  a  goitrous  tumor  is  not  amenable  to  remedial  treatment, 
all  that  can  be  done  is  to  keep  the  health  of  the  patient  as  good 
as  possible,  avoiding  all  exertion  which,  by  inviting  blood  to  the 
part,  would  facilitate  its  further  enlargement  or  bring  on  symp- 
toms of  compression  of  the  vessels  of  the  neck.  If  the  tumor 
enlarges  beneath  the  sterno-cleido-mastoid  or  other  muscles,  and 

'  Medical  Electricity.     London  and  PhUadelphia,  1870,  p.  643. 


AFFECTIOI^S    OF   THE   THYEOID    GLAND.  527 

is  thereby  pressed  injuriously  upon  the  trachea  and  oesophagus, 
the  tension  may  sometimes  be  relieved  by  subcutaneous  division 
of  these  muscles. 

In  post-sternal  goitre,  pressing  upon  the  windpipe,  it  has  been 
recommended  that  efforts  be  made  to  raise  the  tumor  from  its 
bed  and  attach  it  to  the  integuments  above,  so  as  to  relieve  the 
pressure  upon  the  parts.  This  has  been  done  by  means  of  a  lig- 
ature passed  through  the  tumor,  by  which  it  is  kept  directly  un- 
der the  skin  at  the  upper  portion  of  the  neck,  and  then  adhesive 
inflammation  is  induced,  by  the  formation  of  an  eschar  in  the 
integument  by  means  of  the  Vienna  paste  or  some  other  caustic. 

When  the  dyspnoea  is  very  great,  relief  can  sometimes  be 
afforded  by  tracheotomy,  provided  the  compression  exist  at  the 
upper  portion  of  the  trachea,  a  point  which  can  be  determined 
in  some  cases  by  laryngoscopic  inspection,  as  well  as  by  external 
manipulation  of  the  growth.  Pressure  upon  the  nervous  trunks 
will  give  rise  to  dyspnoea,  giddiness,  and  other  symptoms  23ro- 
duced  by  direct  pressure  upon  the  windpipe  and  blood-vessels ; 
and  under  such  circumstances  tracheotomy  would  be  useless. 

Various  operations  have  been  resorted  to  for  the  cure  or  re- 
moval of  a  goitrous  tumor,  but  usually  they  have  been  performed 
more  for  relief  of  the  annoying  and  dangerous  symptoms  than 
on  account  of  the  deformity.  Those  cases  in  which  there  is  no 
immediate  danger  threatening  life,  are  usually  those  which  offer 
the  best  prospect  of  success  in  operating.  It  is  doubtful  whether 
a  severe  operation  be  justifiable  for  the  mere  relief  of  a  deform- 
ity. Halting  between  these  two  ojDinions,  surgeons  are  apt  to 
let  the  goitre  alone. 

Whatever  operation  be  performed,  there  is  great  danger  to 
life,  not  during  the  operation  itself,  though  death  has  occurred 
during  the  extirpation  of  these  tumors,  which  are  sometimes 
inseparably  attached  to  artery,  vein,  and  nerve ;  but  from  the 
excessive  reaction  that  follows,  reaction  which  sometimes  escapes 
control,  and  terminates  fatally  a  few  days  or  a  few  weeks  after- 
wards. Most  of  the  operations  are  adapted  to  the  cystic  form 
of  the  disease  especially. 

Ligation  of  the  base  of  the  gland  is  sometimes  practised,  usu- 


528  DISEASES    OF   THE    NECK. 

ally  after  due  exposure  of  the  tnmor  by  incision  through  the 
integument  and  careful  dissection ;  but  occasionally  the  subcu- 
taneous ligature  has  been  employed.  The  ligature  is  tightened 
from  day  to  day  until  there  is  evidence  of  the  death  of  the  tu- 
mor, when  it  is  removed  in  front  of  the  ligature,  or  cut  off  by 
tightening  the  ligature  still  further. 

Puncture  of  the  tumor  followed  by  the  injection  of  iodine, 
after  withdrawal  of  the  contents  of  a  cyst,  has  been  j^ractised, 
the  trochar  or  the  knife  being  employed  according  to  the  fancy 
of  the  surgeon,  or  the  peculiarities  of  the  case. 

Incision  is  practised  by  dividing  the  integument  for  the  length 
of  two  inches  or  more,  in  the  middle  line,  if  the  tumor  is  in 
front ;  or  in  front  of  or  behind  the  sterno-cleido-mastoid,  if  the 
tumor  is  lateral.  The  parts  being  freely  exposed  by  careful 
dissection,  every  vessel  being  tied  as  soon  as  wounded,  before 
the  cyst  is  opened,  a  puncture  is  made  into  the  cyst,  and  the 
contents  allowed  to  drain  off  slowly.  When  this  has  been  ac- 
complished, the  opening  in  the  cyst  is  enlarged  to  the  extent 
of  an  inch  or  more,  or  to  that  of  the  external  wound,  and  the 
edges  are  kept  separated  by  a  strip  of  oiled  lint.  Suj)puration 
occurs  as  a  result  of  the  inflammation  induced,  and  its  pro- 
ducts escape  readily  by  the  external  opening. 

Excision  consists  in  making  the  incision  through  the  integu- 
ments as  in  the  operation  last  described,  and  then  incising  the 
cyst  so  as  to  get  rid  of  its  contents  ;  after  which  the  edges  of  the 
cyst  are  excised  to  a  greater  or  less  extent,  as  the  case  may  be. 
This  is  a  more  serious  operation  than  incision,  and  much  more 
apt  to  be  attended  with  hemorrhage,  and  followed  by  serious 
results. 

The  introduction  of  a  seton,  either  through  skin  and  tumor, 
or  through  the  tumor  only,  after  division  of  the  skin,  has  been 
practised  with  success;  but  the  treatment  is  very  protracted, 
and  not  devoid  of  the  unpleasant  results  that  follow  the  other 
operations.  Where  the  seton  is  thrust  through  the  skin,  it  is 
recommended  that  it  be  a  silken  thread  passed  by  means  of  a 
large  needle  instead  of  a  regular  seton  lancet,  as  presenting 
less  danger  of  hemorrhage.  Additional  threads  may  be  intro- 
duced as  the  case  progresses. 


AFJB^ECTIOI^S    OF    THE    THYMUS    GLAISTD.  529 

Ligation  of  the  thyroid  ai'teries  has  been  employed.  These 
arteries  sometimes  acquire  the  bulk  of  the  carotids,  and  it  has 
been  thought  that  starvation  of  the  tumor,  by  their  ligation, 
would  deprive  it  of  nutriment  and  thus  induce  absorption. 
This  method  has  no  doubt  been  successful  in  some  instances,  but 
in  others  it  has  not  proved  of  any  benefit,  in  consequence  of 
the  prompt  establishment  of  the  collateral  circulation. 

Extirpation  of  the  tumor  by  the  knife  is  sometimes  employed, 
and  has  often  been  practised  with  success ;  though  the  operation 
is,  as  a  rule,  condemned.  Small  tumors  with  but  few  attach- 
ments are  removed  readily  enough,  but  large  ones  with  exten- 
sive attachments  present  many  difiiculties.  Operations  of  this, 
kind  should  be  performed  slowly  and  cautiously,  the  fingers  and 
knife-handle  being  used  in  the  dissection ;  and  nothing  impor- 
tant should  be  cut  without  being  first  secured  by  ligature.  In 
this  way  large  tumors  have  been  successfully  removed  with 
comparatively  little  hemorrhage.  The  names  of  several  Amer- 
ican surgeons,  especially  those  of  the  two  Warrens  of  Boston, 
are  favorably  known  in  connection  with  tliis  operation.  I  have 
witnessed  one  or  two  successes  under  the  hands  of  Prof.  Pan- 
coast,  and  one,  very  remarkable,  under  the  hands  of  Dr.  Maury 
of  Philadelphia.' 

AFFECTIONS    OF     THE   THYMUS    GLAXD. 

Affections  of  the  thymus  gland,  are  not  of  frequent  occur- 
rence. The  number  of  lobes  of  the* gland,  is  sometimes  found 
increased  ;  and  there  has  occasionally  been  noticed  a  marked 
diminution  of  the  size  of  the  gland,  or  even  its  entire  absence. 

Thymitis. — Inflammation  of  the  thymus  gland  has  been 
occasionally  met  with  and  recognized.  There  is  reason  to  be- 
lieve that  it  sometimes  occurs  unrecognized.  Cases  of  unac- 
counted-for death  have  been  found,  on  dissection,  to  have  been 
due  to  purnlent  inflammation  of  this  gland.  Some  observers- 
believe  that  the  so-called  examples  of  acute  purulent  inflamma- 
tion have  been  due  to  the  suppuration  of  masses  of  tubercles 
which  have  had  this  seat  of  deposit.     That  acute  thymitis  does 

'  Photographical  Review  of  Medicine  and  Surgery.     Pliila.  :  Dec.  1871, 
34 


530  DISEASES    OF   THE    NECK. 

occur,  however,  there  is  sufficient  evidence,  though  the  recorded 
cases  are  few  in  number. 

Dr.  Allan  Burns'  mentions  a  case  of  abscess  of  the  thymus 
gland,  with  discharge  of  its  contents  externally.  An  ulcer 
formed  externally,  from  which  the  patient  drew  out  from  be- 
tween the  laminae  of  the  mediastinum  a  portion  of  lymphatic 
substance  about  three  inches  in  length.  A  very  curious  physico- 
physiological  fact  is  mentioned  in  connection  with  this  case,  and 
which  has  some  bearing  upon  the  mechanism  of  the  respiration. 
When  cicatrization  of  the  wound  was  completed,  it  was  found 
that  the  trachea,  the  innominate  artery,  and  the  thyroid  branch 
of  the  lower  thyroid  artery  were  covered  merely  by  a  thin  pellicle 
of  skin,  a  covering  insufficient  to  prevent  the  external  pressure 
of  the  air  upon  the  trachea,  and  producing  a  permanent  diffi- 
culty in  breathing,  from  sinking  in  of  the  trachea  above  the 
sternum  at  each  deep  inspiration. 

A  case  of  distinct  thymitis  is  mentioned  by  Dr.  Chas.  A.  Lee  ^ 
as  having  occurred  in  his  own  practice,  and  in  which  the  gland 
suppurated  and  discharged  externally  ;  and  a  case  of  acute 
inflammation  is  reported  by  von  Wittich.^ 

Hypertrophy  of  the  Thymus  Gland. — The  thymus  gland 
occasionally  undergoes  hypertrophy ;  but  its  normal  size  varies 
between  such  limits  that  enlargement  is  often  erroneously  sup- 
posed to  exist.  In  the  earlier  part  of  the  present  century,  the 
subject  of  hypertrophy  of  the  thymus  gland  strongly  attracted 
the  attention  of  the  profession.  It  was  believed  by  many  to  be 
the  chief  cause  of  the  laryngismus  stridulus  of  infants,  from 
pressure  of  the  enlarged  gland  upon  the  pneumogastric  nerve,  or 
on  the  recurrent  laryngeal,  or  from  pressure  upon  the  trachea,  or 
on  the  great  vessels.  The  affection  acquired  the  cognomen  of 
thymic  asthma,  and  was  also  known  as  Kopp's  asthma,  in  compli- 
ment to  the  man  who  most  enthusiastically  developed  the  idea 
then  prevalent  of  the  pathology  of  the  affection.     Subsequent 

^  On  the  Surgical  Anatomy  of  the  Head  and  Neck.  Second  Edit.  Glasgow, 
1824,  p.  26. 

^  On  the  Thymus  Gland  ;  its  morbid  Affections,  and  the  Diseases  which  arise 
from  its  abnormal  Enlargement.     Amer.  Jour.  Med.  Sci.^  Jan.  1842,  p.  140. 

^  Hypertrophic  und  theilweise  Vereiterung  der  Thymusdrilse.  Virchoic.  Arch. 
1855,  viii.  4. 


AFFECTIOIS^S    OF   THE    THYMUS    GLAND.  531 

experience  j? roved  that  tlie  premises  vrere  false  on  M'liicli  these 
conchisions  were  based.  It  was  fonnd  that  many  children  per- 
ished of  th}inic  asthma,  withont  any  post-mortem  evidence  of 
enlargement  of  the  gland ;  that  in  some  of  the  fatal  cases  the 
gland  was  actnallj  atrophied,  or  at  least  smaller  than  is  nsnal ; 
and  that  a  few  rare  but  undoubted  eases  of  enlargement  were 
not  prodnctive  of  the  asthmatic  phenomena.  These  demon- 
strations, and  the  fact  that  the  pressure  from  a  tumor  ought  to 
induce  constant  disturbances  of  respiration  rather  than  inter- 
mittent and  spasmodic  manifestations,  gradually  led  to  the  re- 
jection of  the  theory  of  Kopp  and  his  supporters. 

On  one  occasion,  while  operating  on  a  child  some  six  or  seven 
years  of  age,  for  removal  of  foreign  body  from  the  windpipe, 
I  was  somewhat  embarrassed  by  this  gland,  which  projected 
upwards  into  the  wound. 

Degenerations  of  the  Thymus  G-land  are  also  occasionally 
met  with.  Cases  have  been  reported  of  calcareous,  tuberculous, 
and  cancerous  degeneration. 

Sir  Astley  Cooper '  relates  the  case  of  a  young  woman,  nine- 
teen years  of  age,  who  suffered  from  severe  dyspnoea  consequent 
upon  the  sudden  increase  of  a  swelling  of  several  years'  duration 
at  the  inferior  portion  of  the  neck,  and  supposed  to  be  composed 
of  enlarged  lymphatic  glands.  The  patient  died  at  the  end  of 
a  fortnight,  worn  out  by  the  irritation  excited  by  the  difhculty 
in  respiration.  On  examination  of  the  body  it  was  found  that 
the  disease  was  situated  in  the  thymus  gland ;  the  swelling  ex- 
tending fi'om  the  arch  of  the  aorta  to  the  lower  part  of  the 
thyroid  gland,  which  was  also  considerably  enlarged.  *  The  thy- 
mus appeared  of  a  yellowish-white  color,  and  was  divided  into 
several  large  lobes.  It  projected  into  the  innominate  vein,  and 
its  reticular  structure,  on  incision,  was  found  to  be  filled  with 
a  white  pulpy  material.  The  trachea  was  involved  in  the  tu- 
mor and  its  sides  were  compressed  by  it,  so  that  its  transverse 
diameter  was  somewhat  diminished. 

But  little  is  known  concerning  diseases  of  the  thymus  gland, 
and  their  pathology  is  obscure,  except  perhaps  in  those  instances 

1  The  Anatomy  of  the  Thymus  Gland.     Phila.  edit.,  1845,  p.  35. 


532  DISEASES    OP    THE    JSTECK. 

where  turberculous  degeneration  occurs  as  an  expression  of  the 
general  state  of  system  in  certain  subjects  of  phthisis. 

No  special  treatment  can  be  laid  down  for  these  affections. 
They  must  be  managed  upon  general  principles,  and  the  em- 
ployment of  such  measures  as  tend  to  improve  and  maintain 
the  general  well-being  of  the  entire  system.  As  most  of  these 
affections  necessarily  occur  at  an  early  age,  the  resort  to  reme- 
dies usually  employed  for  the  reduction  of  enlarged  glands  can 
rarely  be  advisable. 

The  question  of  an  operation  for  removal  of  the  gland  may 
sometimes  come  up,  but  the  judiciousness  of  the  course  must 
rest  on  the  general  principles  of  legitimate  surgery.  The  ex- 
tirpation of  the  gland,  under  certain  circumstances,  was  sug- 
gested by  Dr.  Allan  Burns,  but  there  are  obvious  reasons  why 
such  a  procedure  should  not  be  determined  on  hastily,  or  un- 
dertaken except  as  an  extreme  measure. 

"  The  state  of  the  thymus  attracted  the  attention  of  Dubois 
in  1851.  He  observed  in  syphilitic  children  a  condition  of  the 
thymus  that  has  since  been  described  by  Depau?  and  Wedl,"" 
though  it  is  not  yet  clear  how  far  syphilis  is  concerned  in  its 
production.  Collections  of  diffluent  matter,  which  may  be  as 
fluid  as  pus,  or  semi-solid,  are  scattered  through  the  interior  of 
the  organ.  Hence,  probably,  a  process  of  a  gummy  kind  pro- 
duces these  dense,  opaque,  yellow  collections.  The  true  nature 
of  the  affection  is  still  uncertain.  Commonly,  no  alteration  of 
any  kind  is  found  in  the  thymus."  ' 

1  Memoir es  de  VAcademie  de  Medecine,  _t.  xvii.  1853,  p.  563. 

^  Pathological  Histology. 

^  Syphilis  and  local  contagious  Disorders.     London,  1868,  p.  226. 


REFEHEN^OES 


UPO]S"    SUBJECTS    TREATED     OF     IN    THE    TEXT. 


The  STibjoined  references,  culled  from  the  author's  index-rentm,  are  arranged  under  "  catch- 
heads  "  as  being  more  convenient  for  consultation  than  an  alphabetic  list  of  authors,  or  a  chrono- 
logic succession  of  articles.  The  list  is  not  presented  as  a  complete  bibliography,  for  a  compilation 
of  that  kind  would  consume  a  greaternumber  of  pages  than  could  be  devoted  to  the  pm-pose. 


Abscess. — Abscess,  in  a  case  of  cynanche  tonsillaris ;  extended  alongside  of 
larynx,  denuding'  hyoid  bone,  etc.  Death  from  hemorrhage.  WAT- 
SON {Med.  Gaz.,  Jan.,  1829).     Am.  Jour.  Med.  Sei.,  iv.  p.  492. 

Another  case.     Webber,  A^n.  Jour.  Med.  8ci.,  vii.  p.  415. 

■ of  pharynx.     Priou  {Bev.  Med.^  April,  1830),  Atn.  Jour.  Med.  Sci.,  vii, 

p.  250. 

LoCKHEAD,  A771.  Jour.  Med.  Sci,  January,  1856,  p.  212. 

■  of  nasal  septum  in  children.      Gxjersant,  La  CMrurgie  des  Enfants., 

Paris,  1864,  47. 
Retro-pharyngeal  abscess.     Chas.  M.  Allin,  N.    Y.  Jour.  Med.,  Nov. 

1851,  p.  307  et  seq.     (58  Cases.) 

of  pharynx.     Bourneville,  Mouvement.  Med.,  1868,  No.  9. 

Retro-pharyngeal  abscess.    Des  abces  retro -pharyngiens  idiopathiques, 

ou  de  I'angiae  phlegmoneuse.     V.  Gatjtier,  Geneve  et  Bale.  1869. 

with  rupture  of   internal  carotid  artery.      Leishmann,    Glasgow  Med. 

Jour.,  Nos.  1,  3,  p.  405,  May. 

Post-oesophageal   abscess    with    secondary  disease  of  cricoid  cartilage. 

Mackenzie.     Trans.  Path.  Soc.    London,  xxi.,  1870,  p.  56. 

of  thyroid  body,  bursting  into  trachea.  Jones,  Liverpool  Med.  &  Surg. 

Bep.,  1869,  p.  133. 

Laryngeal  abscess.     Tobold,  Berl.  Klin.  Woeli.,  1864,  1,  4. 

Abscesses  of  the  larynx.     GoTTSTEiN,  Berl.  Klin.  Woo/i.,  1866,  iii.,  4,  4. 

Laryngeal  abscess  with  consecutive  oedema  of  the  glottis,  during  conva- 

lescence from  tjrphoid  fever.     De  Lacaussade,  Gaz.  des  hop.,  1866, 
116. 

Inflammation  of  larynx  with  abscesses.     Paralysis  of  vocal  cords.     Re- 

covery.    Marcet  and  Hillman,  Lancet,  11,  24  December,  1868. 
Anatomy. — Hyo-epiglottideus  muscle.     Am.  Jour.  Med.  Sci.,  vol.  v.,  p.  475. 


534  EEFEEE]SrCES. 

Ajst ATOMY.  — Nasal  mucous  membrane.     Das  Epithelium  der  Riechschleimliaut 
des  Menschen.     von  Luschka,  Med.  Oeiitralblatt,  1864,  No.  22. 

Eine  quere  Schleimhautfalte   in   der  Kehlkopfhohle.     Sitz-BericM  der 

h.  k.  Akad.  d.   Wiss.     October,  1865,  p.  279. 

Superior   constrictor  muscle  of  the  pharynx.     VON  LtJSCHKA,  Henlen- 

Ffeufen  ZeitscJi.^i  xxxi.,  p.  364, 1867.  See  also  SchmidVsJalirb.,  1867, 
142,  1,  p.  6.     Der  obere  Schniirer  des  m.enschlichen  Schlundkopfes. 

Die  Anatomic  des  menschlichen  Kopfes.    von  Ltjschka,  Tiibingen,  1867. 

Die  Anatomic  des  menschlichen  Halses.    voN  Luschka,  Tiibingen,  1862. 

Der  Schlundkopf  des  Menschen.     vON  Luschka,  Tubingen,  1868. 

Beitrage  zur  Kenntniss  des  Kehlkopf  es  und  der  Trachea.    Verson,  Wien, 

1.868. 

Zur  Anatomic  des  Kehlkopfes  und  dessen   Nachbarschaft.      GtRuber, 

Arch.  f.  Anai.  Phys.  u.  Wiss.  Med.,  1868,  p.  640.  Special  points,  1. 
Lig.  hyo-thyroideum  accessorium;  2,  m.  m.  thyroidei  marginales 
inf  eriores,  «,  incisuras  mediEC  transversus,  J,  incisur£e  mediae  obliquus  ; 
3,  m.  kerato-arytenoideus ;  4,  varieties  of  m.  thyreo-tracheahs,  and 
of  m.  hyo-trachealis. 

Ueber  die  Vertheilung  des  Muskeln  des  (Esophagus  beim  Menschen  und 

Hunde.     Klein,  Allg.  Med.  0.  Ztg.,  December  2,  1868. 

Thyro-hyoid  muscle.     G-EO.  Buchanan,  Journ.  Anat.  &  Physiol. ,  Nov. 

1868,  p.  255. 

Hyo-  and  genio-epiglottic  muscle.     VON  Luschka,   Arc/m  fur  Anat. 

Physiol..^  etc.,  1868,  p.  224.  Also  a  resume  in  Schmidts  Jahrb..,  1869, 
141,  2,  p.  253. 

Ueber  den   Canalis  cranio-pharyngeus   am   Schadel  des  Neugebomen. 

Landzert  [Petersburg.  Med.  Zeitschr.,  xiv.,  3  and  4,  1868,  p.  133), 
Schmidfs  Jahrb.,  1869.  Bd.  152,  No.  1,  p.  11.  Read  in  connection 
with  Luschka  on  adenoid  tissue  of  pharynx,  about  the  bursa  pharyngea. 

On  the  structure  of  the  pituitary  gland.    Peremeschka  ( Virchow  Arch.), 

Gaz.  Med.  Paris,  1869,  No.  13,  p.  171. 

Adenoid  tissue  at  vault  of  pharynx.     Sur  le  tissue  adenoide  de  la  partie 

nasale  du  pharynx  de  I'homme.  VON  Luschka,  Journal  de  VAruito- 
mie,  etc.,  May  and  June,  1869,  p.  225,  with  3  illustrations.  Author 
refers  to  his  work,  "Der  Schlundkopf  der  Menschen,"  Tubingen, 
1868.  Also  to  an  article  from  his  pen,  "  Das  Adenoide  Gewebe  der 
Pars  nasalis  des  menschlichen  Schlundkopfes,"  in  Arch,  fur  Mikrosko- 
pische  Anatomie,  1868,  vol.  iv.,  pi.  1.  This  article  is  followed  by  a 
note  from  Robin  referring  to  his  own  account  of  the  same  tissue  in 
the  Dictionnaire  de  Medecineof  Nysten,  article  pharynx,  second  edit., 
1855,  and  subsequent  editions. 

On  the  mucous  membrane  of  the  cavity  of  the  larynx.     VON  Luschka, 

Arch,  fur  mikroskop.  Anat.,  t.  v.,  1,  1869,  p.  126.  Schmidts  Jahrb., 
t.  V.  4,  1869,  p.  142.     Oa,z.  Hebd.,  1869,  24,  p.  382. 

Beitrage  zur  Kenntniss  der  Nerven-,  Blut-  und  Lymphgefiisse  der  Kehl- 

kopfschleimhaut.     Arch,  fur  mikroskop.  Anat.,  1871,  vii.,  2,  p.  166. 

Der  Kehlkopf  des  Menschen.     H.  VON  Luschka,  Tubingen,  1871. 


REFERENCES.  535 

Anatomy. — TJeber  die  acinosen  Drusen  der  Schleimhaute,  insbesondere  der 
Nasenschleimhaut,  Ant.  Heidenheijj;.     Breslau,  1871. 

Aneurism. — Of  transverse  part  of  arch  of  the  aorta,  size  of  an  orange  ;  left 
pnenmogastric  in  front  somewhat  flattened  by  the  pressure,  the  re- 
current passed  behind.  Aneurism  had  opened  into  oesophagus,  and 
the  stomach  was  filled  with  blood.  J.  H. ,  £et.  31,  a  hawker,  intem- 
perate, had  experienced  stoppage  in  throat  and  loss  of  voice  for  seven 
weeks  before  admission,  June  16th,  1863 ;  and  for  eight  days  had 
had  difficulty  in  swallowing  solids.     Died  June  20th,  1863. 

Of  aoi-ta;  producing  aphonia.     Flint,  Medical  Record^  vol.  3,  p.  355. 

Opening  into  left  bronchus,  avoiding  the  left  recurrent  nerve,  wholly 

without  spasmodic  symptoms. 

Of  aorta  ;    tracheotomy ;    terminated   three   days   after  by  rupture  into 

trachea.  Gumming,  Dub.  Quart.  Jour.,  May,  1868.  Suffocation  was 
imminent,  from  compression  of  trachea  and  tension  of  recurrent 
laryngeal  nerves. 

Abdominal ;  inducing  aphonia,   cough,   dyspnoea,  etc.     Aphonia  due  to 

oedematous  condition  of  vocal  cords.  Aphonia  was  temporary  and 
reciu-rent.  Cough  dry,  barking  and  spasmodic.  W.  Moore.  Dublin 
Quart.  Jour..,  August,  1869,  p.  13. 
Of  aorta.  Two  cases  causing  pressure  on  left  recurrent  nerve  and  pa- 
ralysis of  muscles  of  larynx.  Morell-Macicekzie.  Remarks  of  Dr. 
C.  J.  B.  Williaras,  Sibson  (case  rei^orted  in  Path.  So.  Trans.)  Path. 
So.,  April  19,  1870.     Med.  Times  &  Oaz.,  June  4,  1870,  p.  620. 

Case  opening  into  trachea.     Tracheotomy.     Autopsy.     T.  A.  Barker,  _ 

St.  Thomas  Hospital  Reports.,  1870,  p.  331.  Some  account  of  three 
other  cases  producing  constriction  of  glottis,  where  tracheotomy  pro- 
longed life,  but  only  for  a  few  hours. 

Of  aorta  ;  implicating,  in  its  pressure,  the  recuxrent  laryngeal  nerve,  the 

oesophagus,  the  right  bronchus,  and  the  sympathetic  nerve  of  the 
right  side,  which  was  irritated  but  not  paralyzed  ;  the  right  pupil  was 
consequently  dilated,  not  contracted.  Stewart,  Edinb.  Med.  Jour. , 
December,  1870,  p.  555. 

Two  cases  of  arch  of  aorta  involving  pressure  on  left  recurrent  laryngeal 

nerve.     Mackenzie,  Trans.  PatJi.  So.  London,  xxi.,  1870,  p.  129. 

Of  arch  of  aorta,  proving  fatal  by  pressure  on  left  recurrent  nerve  ; 

irregular  origin  of  the  large  vessels.  PEACOCK,  with  lithograph. 
Trans.  Path.  So.  London,  xxi.,  1870,  p.  134. 

The  diagnosis  of  aneurism  of  the  aorta  by  the  aid  of  the  laryngoscope. 

Johnson,  Brit.  Med.  Jour.,  December  23,  1871,  p.  720. 
Anosmia. — Loss  of  smell  from  local  etherization  in  perf orining  of  experiments. 
A  case  in  Virch.  Arch. ,  iv. ,  41,  1867.    Si/d.  So.  Bienn.  Retrosp. ,  1867-8. 

Cases  illustrating  the  physiology  and  pathology  of  the  sense  of  smell. 

Ogle,  Med.  Chir.  Trans.,  London,  1870,  p.  263,  with  several  other 
references.     Abstract  in  Brit.  Med.  Jour.,  February  12,  1870,  p.  66. 

Recherches  sur  la  perte  de  I'odorat.     Notta,  Arch.    Oen. ,  April,  1870, 

p.  388. 


536  EEFERElSrCES. 

Anosmia.  — Case  of,  occurring  after  a  blow  on  tlie  occiput.     Hamilton,  Am. 

Journ.  Med.  Sci,  April,  1871,  p.  418;  refers  to  case  in  same  journal, 

AprU,  1870,  p.  537. 
Aphonia.  — Curious  case  produced  by  fright,  in  a  woman  at  seTenth  month  of 

pregnancy.     BoiviN,  Am.  Jour.  Med.  Sd.,  vol.  vi.,  p.  220. 
■ Intermittent.     Eennes  {Arcli.  Gen.,  June,   1829),  A7n.  Jour.  Med.  Sci., 

vol.  vi.,  p.  222. 
Intermittent.     30  years'  duration.     Olliviek  {Arch.  Oen.,  June,  1829), 

Am.  Jour.  Med.  Science,  vol.  vi.,  p.  222. 

from  bayonet  wound  of  pharynx  ;    pressure  of  retained  point  on  laryngeal 

branch  of  par  vagum.  Instantaneous  restoration  of  voice  on  removal. 
Lakkey  (Case  IV.),  Am.  Jour.  Med.  Sci.,\o\.  viii.,  p.  514.  See  Case 
v.,  ibid.,  Tracheotomy,  death. 

Loss  of  voice  from  inclusion  of  the  par  vagum  in  a  ligature  of  the  carotid 

artery  in  a  case  of  attempted  suicide.  Horner,  Am.  Jour.  Med. 
Sci,  vol.  X.,  p.  403. 

Cases  dependent  on  an  affection  of  the  head.     Webster  (London  Med. 

&  Pliys.  Jour.,  Oct.,  1832),  Am.  Jour.  Med.  Sci.,  vol.  xii.,  p.  221. 

Case  of  cure  by  smoking  mercurial  cigarettes.     Nevins,  Ayn.  Jour.  Med. 

Sci.,  April,  1859,  p.  541. 

Studien  und  Beobachtungen  liber   Stimmband-Lahmung.     Gerhardt, 

Berlin,  1863. 

Following  phrenesia  potatorum.     Deutsche  Klinik,  1866,  p.  56. 

in  Bright's  disease.     Waldenburg,  Deutsche  Klinik,  1866,  p.  214. 

Simulating  laryngeal  phthisis.     Cure  by  galvanism.     This  power  of  re- 

storation of  voice  explains  the  pretended  cures  of  laryngeal  phthisis. 
Krishaber,  Oaz.  hebd.,  1868,  No.  42,  p.  661. 

Electro-puncture  in  obstinate  cases.     Mackenzie.     See  an  article  iu 

The  Practitioner  for  March,  1869,  p.  148. 

from  laryngeal  paralysis.     Mackenzie,  Med.   Times  &   Oaz.,  April  3, 

1869,  p.  356. 

from  paralysis  of  cords.     Knight,  Boston  Med.  &  Surg.  Jour. ,  Feb.  25, 

1869. 

Etudes  medicales  sur  le  Mont-Dore.    Neuvieme  memoire  de  la  cure  ther- 

male  du  Mont-Dore  dans  le  traitement  des  affections  chroniques  du 

larynx  et  en  particulier  de  I'aphonie.     G.  Richei,ot,  Paris,  1869. 
Treated  by  Galvanism.     Marcet  {Trctns.  Clin.  So.  London,  1868),  Am. 

Jour.  Med.  Sci.,  Oct.,  1869,  p.  472. 
Chief  causes  of  hoarseness  and  aphonia,  with  hints  on  treatment.     Geo. 

Johnson,  Med.  Times  &  Oaz.,  Jan.  15,  1870,  p.  60. 

Treatment  by  external  manipulation.     Cases,  etc.     Oliver,  Am.  Jour. 

Med.  Sci,  April,  1870,  p.  305. 

from  blow  upon  larynx.     Le  Gros  Clark's  Lectures  on  Surgical  Diagno- 

sis, 1870,  p.  229. 
Alum.  — Insufflation  of,  in  angina  tonsillaris,  variolous  angina  and  oedema  of 
the  glottis.     L^NNEC  {Bev.  Med.,  Oct.,  1825),  Am.  Jour.  Med.  Sci, 
vol.  iv. ,  p.  500. 


EEFEEENCES.  53  T 

Alum. — Lozenges  of,  instead  of  gargles,  in  throat  affections ;  made  up  with 
sugar,  tragacanth,  and  dilute  laurel-water.  Am.  Jour.  Med.  Sci., 
Jan.,  1860,  p.  219. 

Cancer. — Cancer  du  larynx.     Ai'c7i.  Oen.,  1870,  p.  234. 

of  larynx.     Rob't  Hamilton  says  there  are  no  distinguishing  characters 

to  enable  one  to  pronounce  at  once  upon  the  nature  of  the  growth  in 
the  soft  ulcerative  forms  of  cancer,  such  as  of  the  uterus,  pharynx, 
etc.  Illustrated  by  specimens  of  tongue,  larynx,  etc.  Liverpool  Med. 
(&  Surg.  Bep.,  October,  1870.     Banking'' s  Aist..,  January,  1871. 

Primary  cancer  of  larynx.     Desormeatjx  {Gas.  hehd.,  1870,  No.  28), 

Banking^ s  Abst.,  January,  1871,  p.  189. 
Cakoiid. — Ulceration  of  carotid  artery  from  cervical  tumor.     Adenite  sup- 

puree  du  cou.    Ulceration  de  la  carotide  primitive  et  de  la  carotide 

externe.    Hemorrhagie.    Mort.    VERNEUiLfor  Dauve,  (rffls.  (?(5s7to^., 

August  30,  1870,  p.  388. 
Cartilage.- — Cartilaginous  tubes.     Le  role  physiologique  des  tubes  cartUa- 

gineux ;  trachee-artere,  trpmpe  d'Eustache,  et  portion  cartilagineuse 

du  conduit  auditif.     Prat.    Oaz.  liehd.,  1869,  No.  6,  p.  93.  Gaz.  Med. 

Paris,  1869,  No.  11,  p.  139.     La  France  Med.,  1869,  No.  10,  p.  76. 

Cicatrization  des  cartilages.     Regenerations  animales ;  Legros,  Experi- 

ments on  trachea  of  animals,  etc.     Gas.  Med.  Paris,  1869,  No.  6,  p.  75. 

Fibroid  degeneration  of  cartilages  of  larynx.     Mackenzie,  Trans.  Path. 

So.  London,  xxi.,  1870,  58,  illustrated. 
Catheterization.^ — Catheterism    of  larynx.       Ueber    d.   KatJieterismus    d. 

Larynx.     Weinleichner,  Jnhrb.  f.  Rinderkr.,  N.  F.  iv.,  1,  p.  69. 
Catarrh. — Catarrh  des  Larynx  als  Symptom  des  chronischen  Morbus  Brightii. 

Schuster,  DeutscJie  KUnik,  1866,  p.  185. 

Laryngeal.     Treatment  of,   Gerhardt  ;    i'  Union  Med.  de  la  Gironde, 

1867,  p.  534. 

Rhinitis.    Ueber  chronischer  Rhinitis  und  Folgen  derselben.     Uhlen- 

BROCK,  Beutselie  KUnik,  1869,  pp.  193,  213,  232. 

Chronischer  Rachenkatarrh ;  Schlingbeschwerden  in  Folge  von  Parese 

des  Gaumensegels ;  Heilung  durch  den  Inductions- Strom.  HOFMAN, 
Memarabilien,  xiv.,  8,  1869. 

Of  the  form  known  as  Hay  Asthma.    BiNZ  publishes  a  letter  from  Helm- 

HOLZ,  as  to  the  value  of  local  injections  of  muriate  of  quinia.  Prac- 
titioner, November,  1869. 

— —  Notes  of  a  lecture  on  Hay  Fever.  Thompson,  Brit.  Med.  Journ.,  Janu- 
ary 21,  1871,  p.  58. 

Cleft -Palate.— Staphylorraphy.     Warren,  Am.  Jour.  Med.  Sci,  iii.,  p.  1. 

Staphylorraphy.     Diepfenbach,  Am.  Jour.  Med.  Sd.,  iii.,  p.  471. 

Staphylorraphy.     Case  followed  by  death.     Angina  said  to  be  a  common 

sequel.  Am.  Jour.  Med.  Sci. ,  vii. ,  p.  545. 
— —  Staphylorraphy.     HosACK,  Am.  Jour.  Med.  Sci.,  xii.,  p.  556. 

Uranoplasty.     Hermann,  Gas.  Med.  Paris,  1867,  p.  782. 

Staphylorraphy.    Influence  of  vocal  exercises  on  the  results  of.    Trelat. 

(?os.  7ieM,  1867,  p.  125. 


538  EEFERE]SrCES. 

Cleft-Palate. — Sarazin.     Gaz.  Med.  Strasbourg,  1868,  p.  225. 

Uranoplasty.     Ehrmann,  Considerations    pratiques    sur  ruranoplastie, 

Gaz.  Med.  Strasbourg,  1868,  p.  21. 

Uranoplasty.     Billroth's  case,   Woch.  k.  k.  Gaz.   Wien,  1868,  p.  417. 

Uranoplasty.      Heiberg,    Fall   von    Uranoplastik   u.    Staphylorraphie, 

Norsk.  Mag.,  2.  E.  xxii.,  7,  Ges.  Bern,  p.  172. 

Uranoplasty.     Whitehead,  Am.  Jour.  Med.  Sci,  July,  1868,  Oct.,  1868. 

Uranoplasty.     Beitrage   zur  Uranoplastik,   Bryk,    of  Kiakau  {Oesterr. 

Zeitsch.  f.  prakt.  Heilk.,  xiv.,  1,  2,  3,  4,  7,  and  8,  1868),  Schmidt's 
Jahrb.,  1869,  Bd.  142,  No.  1,  p.  74. 

Cure  of,  in  cliildren  by  operation,  with  description  of  an  instrument  for 

facilitating  the  operation.  Smith,  Am.  Jour.  Med.  Sci. ,  April,  1868, 
p.  541. 

Restoration  of  articulation  in,   by   artificial  palates.     SuERSEN,   Med. 

Times  and  Gaz.,  Jan.  16,  1869,  p.  75. 

Obserrations  on  the  operations  for,  with  cases.     Annandale,  Edinb. 

Med.  Jour.,  AprH,  1869,  p.  869. 

Surgical  treatment  of  cleft  of  hard  palate,  with  cases.     Whitehead,  N. 

T.  Med.  Jour.,  April,  1869,  p.  1. 

Operation  for,  on  a  girl  five  years  of  age.     Adams,  Lancet,  June  12, 1869. 

Cigarettes. — Mercurial.      Formula  for.     Nevius,   Am.   Jmir.   Med.    Sci., 

April,  1869,  p.  539.     Their  use  in  aphonia,  diseases  of  nasal  jDassages, 
frontal  sinuses,  etc. 
Cortza. — Inhalation  of  fumes  of  opium  in.     Am.  Jour.  Med.  Sci.,  July,  1855, 
p.  207. 

G-lycerine  in.     Stille's,  TJierapeutics,  1868,  vol.  1,  p.   132. 

Camphorated  and  etherized  vapors  of  tar  in.     La  Tribune  Med.,  1868, 

p.  571. 

of  children.     SniON,  On  Coryza  and  the  Catarrh  of  children.     Journ.  f. 

Kinderkr.,  U.  [xxvi.,  11  and  12],  p.  337,  jSTov.  and  Dec,  1868. 

Inhalation  of  Sulphur  in,  spoken  of  by  Avicenna,  "  restringit  coiyzam 

stiffumigatio. "  Popham,  On  the  Employment  by  the  ancients  of  the 
vapors  of  sulphur  as  a  disinfecting  and  curative  agent,  Dub.  Quart. 
Jour.  Med.  Sci.,  May,  1869,  p.  489. 

Mittel  gegen  den  Schnupfen.     VON  Hager,  MoriAia  ^ther  piceo-cam- 

phoratus,  seu  Tinctura  antecoryzea  spirabilis  (Pharmac.  Centr.  Halle 
f.  Bent.,  1868),  Me/nor ab Hie n.  May  31,  1869,  p.  44. 

Syphilitic.     Lanceraus  on  Syphilis,  Syd.  Ed.,  1869,  vol.  ii. ,  p.  147. 

Cricoid. — Cricoid  Cartilage.     Complete  division  of,  and  oesophagus.     Cut- 
ting, Am.  Jour.  Med.  Sci.,  Jan.,  1853,  p.  95. 

Prilnary  caries  of,  with  secondary  abscess.     Mackenzie,   Trans.  Path. 

So.  London,  xxi.,  1870,  p.  46,  with  cuts  of  laryngoscopic  appearances. 

Large  tumor  removed  from  posterior  surface  of.     Mackenzie,  Trans. 

Path.  So.  London,  xxi.,  1870,  p.  53,  with  cuts  of  laryngoscopic  and 
microscopic  ajipearances. 

Secondary  disease    of,    from    post- oesophageal    abscess.      Mackenzie, 

Trans.  Path.  So.  London,  1870,  p.  56. 


EEFEREISrCES.  539 

Croup. — Efficacy  of  tobacco  in.   Chapman,  Am.  Jour.  Med.  Sci. ,  vol.  i.,  p.  477. 
Observations  by  J.  R.  CoxE,  Am.  Jour.  Med.  Sci.,  vol.  iii.,  p.  56. 

Jadelot's  treatment  of.     Am.  Jour.  Med.  Sci. ,  vol.  iii. ,  p.  207. 

Ley  on  Croup,  etc.     London,  1836.     An  essay  on  the  Laryngismus  Stri- 

dulus, or  croup-like  inspiration  of  iofailts,  etc. 

Observations  on  the  Pathology  of  Croup,  etc.     Green,  New  York,  1849. 

in  adult.   Specimen.  Jackson,  A7n.  Jour.  Med.  Sci..,  April,  1853,  p.  368. 

Cure  by  Steam.     Storer,  Am.  Jour.  Med.  Sci,  April,  1853,  p.  359,  ibid. 

April,  1858,  p.  352. 

Cases  treated  with  arg.-nit.  Am.  Med.  Jour.  Med.  Sci.,  April,  1854,  p.  346. 

Cases  treated  successfully  with  pot.  iod.     G-RiscOM,  Am.  Jour.  Med.  Sci. , 

July,  1854,  p.  286. 

fatal  case  at  15  months.     Specimen.     Am.  Jour.  Med.  Sci.,  Oct.,  1854, 

p.  346. 

Peaslee,  Monograph.  Review.     A7n.  Jour.  Med.  Sci.,  April,  1855,  p.  472. 

Trousseau,  Tracheotomy  in.     Am.  Jour.  Med.  Sci.,  July,  1853,  p.  237. 

NewmAjST,  prize  essay  on.     Am.  Jour.  Med.  Sci.,  Jan.,  1856,  103. 

Martyn,  severe  inflammatory.     Am.  Jour.  Med.  Sci.,  Jan.,  1856,  p.  210. 

Sulj)hate  of  copper  in.     Honerkopp,  Am.  Jour.  Med.  Sci.,  April,  1856, 

p.  473,  ibid.  Oct.,  1859,  p.  538. 

Belladonna  and  mercurial  ointment  locally  in.     Am.   Jour.  Med.   Sci., 

April,  1858,  p.  340. 

Glycerine  in.     Mayer,  Am.  Jour.  Med.  Sci.,  April,  1858,  p.  338. 

Tepid  solutions  of  sodse  chloras  into  trachea  in.     Barthez,  Am.  Jour. 

Med.  Sci.,  Oct.,  1859,  p.  544. 

Comparative  results  of  treatment  of,  by  tracheotomy  and  by  medicature 

during  the  years  1854-8.     Bakthez,  Am.  Jour.  Med.  Soi.,  July,  1860, 
p.  231. 

Anleitung  zur  Tracheotomie  bei  Croup.     Lissard,  Giessen,  1861. 

Ice-water  in.     McFarland,  Am.  Jour.  Med.  Sci.,  April,  1861,  p.  607. 

Movement  cure  in.     Die  naturgemasse  Behandlung  der  hiiutigen  Bralme. 

Becker,  Cassel,  1865. 

Der  Croup.     Pauli,  Wurzburg,  1865. 

Der  Croup  oder  die  hautige  Braune.     Steinbacher,  Augsburg,  1867. 

Lisufiiation  of  nitric  acid  in.      Gaz.  Jtebd.,  1867,  p.  303,  418. 

Inman,   advises  moisture  and  warm  temperature,  Liverpool  Med.   and 

Surg.  Rep.,  vol.  i.,  1867,  p.  17. 

33  cases  of  tracheotomy  in.     Oaz.  Med.  Strasbourg,  1867,  p.  295. 

Cases  of,  tracheotomy.  Lime-water,  etc.     Gaz.  Med.  Strasbourg,  1868,  p. 

106,  171. 

Treatment   by   inhalation   of  moist   vapors   of    sulphuret    of    mercury. 

Abeille,  Gaz.  Med.  Paris,  1867,  pp.  527,  569,  582,  598. 

Bregeant,  ibid.,  1868,  p.  80. 

— -  fatal  case  in  a  boy  ^t.  15  years.     Middleton,  Am.   Jour.  Med,  Sd, 

Jan.  1868,  p.  120. 
fatal  case  in.    Prentiss,  A)7i.  Jour.  Med.  Sci.  April,  1868,  p.  412. 

cases  with  result  of  operations,  Gas.  hebd.,  1868,  p.  811,  361;  442. 


540  REFERENCES. 

Ceo  UP. — Bromine  in.     Ozanam,  Ain.  Jour.  Med.  8ci.,  April,  1868,  p.  536. 

Bromine  in.     Medical  Record^  vol.  iii.,  p.  440. 

Jacob:  on.     Am.  Jour.  Ohstet.^  May,  1868.     Am.  Jour.  Med.  Sci,  Oct. 

1868,  p.  587. 
^  Etude  sur  le  croup  apres'la  tracheotomie.   Sanne.     Paris,  1869. 

Acetate  of  potash  in  large  doses,  3  ij  in  eau  sucre  in  24  hours  ;  produces  a 

slight  cough,  facilitating  expectoration  of  membranes.  Labat  (Journ. 
de  Med.  Bordeaux)  Practitioner.,  June,  1869,  p.  377. 

Injections  of  lime-water,  by  Pravaz'  syringe  inserted  between  rings  of  tra- 
chea. Albtj  of  Berlin,  Berlin  Klin.  Woch.  1869,  No.  5,  note.  Union 
Med.  Bulletin  Gen.  de  Thera^.,  July  30,  1869,  p.  91. 

Formation  of  rale  in  croup.     G-enesis  des  "  Cliquetis"  genannten  Gerau- 

sohes  beim  diphtheritischen  Croup.  Kuchenmeister,  Berlin  Klin. 
Woeh.,  No.  2,  1870.   Wein.  Med.  WbcJi. ,  March  12,  1870,  No.  18,  p.  287. 

A.  Webee,  of  Darmstadt,  finds  lactic  acid  useless ;  also  lime-water.    Wien. 

3fed.  Woeh.,  BeUagezu,  No.  20,  1870. 

Pathology  of.      Fibrinous  exudation  soUdified  by  presence  of  carbonic 

acid.     See  experiments  of  B.  W.  Richaedson,  Lancet,  Sept.  24,  p.  438. 

De  Croup  und  seine  Behandlung  durch  Grlycerininhalationen.     Stehbee- 

gee,  Mannheim,  1870. 

Specimen  of  croupal  false  membrane  from  tracheal  bifurcation  to  epi- 

glottis. PoETEE.  Doubts  expressed  by  Society  whether  not  diph- 
theria, Tra7i.  Path.  So.  London.,  xxi.,  1870,  p.  445. 

Quinine  in;    Retrospect  in  Am.  Journ.  Med.  8ei.,  April,  1871,  p.  598. 

Cough. — Hysterical  and  spasmodic.  Am.  Jour.  Med.  Sci,  July,  1854,  p.  232. 

On  cough.     Semple,  London,  1858. 

On  winter  cough.     DOBELL,  London,  1866. 

study  of,  Nothnagel,  AUg.  Med.  Cent-Zeitg.^  October  17,  1868,  p.  720. 

Gaz.  Jiebd.,  1868,  813,  Virch.  Arch.  44,  B.  1.  H. 

Der  hysterische  Krampfhusten.     Theodoe,  Greifswald,  1868. 

from  foreign  body  in  ear.     Toynbee,  Diseases  of  the  Ear.,  London,  1868, 

p.  39. 

On  the  physiology  of  Ear-cough.     Claeke,  Brit.    Med.  Jour.,  January 

15,  1870,  p.  51. 

Ear-cough.     Bush,  ibid.  p.  53. 

fracturing  10th  rib  a  little  anterior  to  tubercle,  in  a  pregnant  woman  ast. 

53  years,  with  a  relaxed  uvula.     Miall,  Brit.   Med.  Jour..,  January- 
7th,  1871,  p.  8. 
Deafness. — From  syphilitic  ulcers  of  pharynx.     (Van  Swieten   and  others 
quoted.)     Lanceeaux,   on  syphilis,  vol.   ii.,   p.  112;  also  from  de- 
struction of  bones  and  other  venereal  sequehe. 

On  throat  deafness.     Yeaesley,  11th  Edit.  London,  1868. 

Deglutition. — Sur  Tusage   de   I'epiglotte  dans  la  deglutition.     Majendie, 

reference  to,  in  Am.  Jour.  Med.  Sci,  vol.  viii.,  p.  223. 

Rheumatic   affection   of   maxillary   articulation   sometimes    preventing 

deglutition.  Fahnestock's  liniment  in,  Am.  Jour.  Med.  Sci.,  vol. 
xi,  p.  60. 


REFEKENCES.  541 

Deglutition. — Autolaryngoscopic  observations  on  the  mechanism  of  degluti- 
tion.    Krishaber,  Union  Med.  1865,  64. 

Autolaryngoscopic  observations  in  deglutition.     G-uinier,  Qaz.  des  hop. 

1865,  59,  Gaz.  hebd.,  1865,  23,  31. 

Deglutition,  on.     MoURA,  Gaz.  Jiebd.,  1867,  pp.  221,  582. 

Jugglery,  etc.     Med.  News  <fe  Lib. ,  1868,  p.  143. 

Le  nouveau  dictionnaire  de  medecine  et  les  experiences  autolaryngos- 

copiques  de  Guinier  de  Montpellier.      Gaz.  liebd.^  1869,  p.  342. 

L'acte  de  deglutition,  son  mecanisme.     Motjra,  Paris,  1869. 

Deglutition ;   action   of  sensitive   nerves   in ;    allusion  to  experiments  of 

Waller  and  Prevost.   Med.  Times  &  Gaz..,  1869,  September  4,  p.  286. 
Jmbr.  Psyeh.  Med.,  April,  1871,  p.  408  from  J.9-cA.  de  Physiol..,  1870. 
Diphtheria. — The  paralysis  of,  dependent  upon  lesion  of  the  great  sympa- 
thetic.    Remak,  Berlin.  Klin.  Woch.,  1854,  No.  13. 

Chlorine  ia.  Am.  Jour.  Med.  Sci.,  April,  1859,  p.  545. 

Throat  paralysis  following;.  Reynolds,  Am.  Jour.  Med.  Sei.,  July,  1850, 

p.  285. 

Creasote  locally  in.   Am.  Jour.  Med.  Sci,  AprU,  1861,  p.  608. 

Diphtheria;    its  nature  ajid  treatment.     Slade,  Phil.,  1861;  being  the 

dissertation  to  which  the  Fiske  fund  prize  was  awarded,  July  11,  1860. 

On  the  treatment  of  Diphtheria.     Chapman,  Boston,  1 863. 

Paralysis  after.     Moore,  Med.  Press  &  Circ,  1866. 

Case  of,  by  inoculation.     Paterson,  Gaz.  Med.  Paris,  1867,  p.  647. 

Paralysis,  consecutive  to  a  wound.  Gaz.  hebd.,  1867,  p.  14. 

Its    nature,    and    the    consecutive    paralysis.      Thoresen,     {Jour.   f. 

Kind.,  1866,  No.  9   &  10),  Rev.  m  Gaz.  Med.  Strasbourg,  1867,  p. 
259. 

Paralysis  of  palate,   diaphragm,  and  posterior  muscles  of  neck ;   rapidly 

cured  by  strychnine  and  electricity.     Gaz.  hebd.,  Novenaber  22,  1867, 
p.  746. 

Bromine  in,  Med.  Becord,  vol.  iii.,  p.  441. 

Laryngoscopic  examinations  in,  Z'  JInion  Mid.  Gironde,  October,  1868, 

p.  602. 

Acidulated  solution   of  pepsiae   as  a  solvent  for  false   membrane   in. 

Doughty,  Richmond  <& Louisville  Med.  Jour.,  1868,  p.  591. 

Solubility  of  false  membranes  of.      Bricheteau  &  Adrian,    Union 

Med.  Gironde,  August,  1868,  p.  516. 

Pharyngite   pseudomembraneuse.      Betheder,    Union  Med.     Gironde, 

July,  1868,  p.  461. 

Local  use  of  sublimate.     Betz,  Memorabilien,  1868,  p.  168. 

Iodine  inhalation  in.     CURRAN,  Lancet,  1868,  Oct.  16,  No.  17. 

Case  of,  with  tracheotomy.     Prentiss,  Am.  Jour.  Med.  Sci.,  April,  1868, 

p.  412. 
— —  Treatment  by  cauterizations.  Cambrellin,  Bulletin  de  V Academic  Boyale 
de  Medecine  de  Belgique,  1868,  p.  552. 

Treatment  by  sulphur.     Ullersperger,  Journal  fur  Kinderkr.,  1868, 

26,  546,  5.  &  6.  Memorabilien,  May  8,  1869,  p.  21. 


542  EEFEEElSrCES. 

Diphtheria. — Treatment  by  balsam  of  copaiba  and  cubebs.  On  the  prin- 
ciple of  their  properties  in  drying  up  sources  of  mucous  secretions, 
therefore  so  useful  in  catarrhal  affections,  especially  of  the  adynamic 
and  gangrenous  varieties.  Trideau,  Brit,  and  For.  Med.  Chir.  Rev. , 
Oct.,  1868.     RanUnq's  Abst.,  1869,  p.  110. 

Treatment  by  flowers   of   sulphur.     Barbosa,  Lisbon,  1868.     Eev.  in 

Qaz.  Med.  Paris,  1869,  p.  271. 

of  larynx,  treatment  of.   Zur  Behandlung  d.  Kehlkopfdiphtheritis.    Albtj, 

Berl.  klin.  Wooh.,  vi.  5.,  p.  50,  1869;  again  Deutsche  KUnik.,  1869, 

No.  31,  p.  290. 
Anatomy  of.  La  diphtherite  et  le  croup  du  pharynx  et  des  voies  aeriennes 

au  point  de  vue  anatomique.     Wagner.     Translated  from  Arch,  der 

Heilkunde;  Oaz.  Med.  Paris,  1869,  No.  29,  p.  393. 
Fungus  of.     Letzerich,  in  Virchow's  Archiv,  1869,   xlv.   327-333,  and 

xlvi.  229-233,  says  the  membranes  are  due  to  a  fungus  {zygodesmus 

fuscus)  developed  on  the  surface  of  the  mucous  membrane,  and  in  its 

tissue. 
Parasitic  nature  of.  LoEwnsrsoN  and  Klotzch,  Wien  Med.  Presse,  x.  19, 

1869. 
, Hemiplegia  of  right  side  from.     Bouchut,  Oaz.  d.  hop. ,  103. 

Paralysis  from ;  cases.  Easton,  Olasgoio  Med.  Jour.,  N.  S.  Aug.  14,  p.  453. 

Strychnia  in ;  Diphtherit.  Lahmung  d.   Rumpfes,   der  Extremitaten,  d. 

Fauces  u.  d,  Nervi  laryng.  sup.  ;  rasche  Heilung  bei  Anwendung  von 
Strychnia.     Leube,  Arch.  f.  Klin.  Med. ,  vi. ,  2  a  3,  p.  266. 

Value    of    sulphur    in.      Apparently    a    fair    exposition ;  entitled    Die 

Epidemische  Diphtheritis  und  deren  schneUste  Heilung.  Alban 
LtJTZ,  Wiirzburg,  1870,  pp.  62. 

Relations  with  Scarlatina.    Mettenheimer,  Memoraoil.  xiv.  8.  Thomas  ; 

Louis;  ibid.,  xiv.  9. 

Nasal.  Orr,  Scott,  Gairdner;   cases.     Glasgow  Med.  Jour.,Maj,  1869, 

p.  395. 

and  lime-water.    Kuchenmbister,  Allg.  Med.  Cent.-Zeltg.,  Feb.  5,  1870, 

p.  125  and  Feb.  12,  1870,  p.  150. 

Sudden  death  during  convalescence  from.     White,  Med.  Times  &  Gaz., 

April  30,  1870,  p.  464. 

TJeber  die    Beziehung    der    Rachen- — Diphtherie    zur    Septhamie    und 

Pyohcimie.  Prof.  Billroth;  a  series,  commencing  No.  7,  1870.  Wien. 
Med.   Woch. 

XJselessness  of  cauterizations.  Dr.  Schtjller  stated  ta  the  48th  Versamm- 

lung  Deutsclter  Naturforseher  imd  Aerzte,  that  he  had  entu-ely 
abandoned  cauterization  of  the  pharynx,  larynx,  and  conjunctiva  in 
diphtheria.  In  numerous  cases  he  had,  as  an  experiment,  cauterized 
only  one  side  of  the  fauces,  and  he  had  always  been  led  to  the  same 
conclusion :— 1st,  That  the  membrane  remained  attached  longer  on 
the  side  which  had  been  cauterized  than  on  the  other ;  2d,  that  even 
the  most  energetic  application  of  nitrate  of  silver  failed  to  arrest  the 
reproduction,  or  to  prevent  the  extension  of  the  membrane ;    3d,  in 


EEFERENCES.  543 

some  cases,  serious  tumefaction  and  inflammation  of  the  cervical 
lymphatics  followed  the  application  of  the  caustic.  In  these  views  he 
was  supported  by  Ebert,  Stiebel,  Cohen,  Rinecker  and  others,  who 
directed  the  use  of  small  bits  of  ice  to  be  constantly  allowed  to  melt 
in  the  mouth,  and  employed  a  gargle  of  chlorate  of  potash,  alcohol, 
permanganate  of  potassa,  carbolic  acid,  etc.  The  Med.  Times.,  Feb. 
1,  1871,  p.  166. 

DiPHTHEKiA. — After  excision  of  tonsils,  etc.;  fatal;  specimens.  Heslop, 
Brit.  Med.  Jour.,  March  25,  1871,  p.  323. 

Dysphagia. — From  displacement  of  hyoid  bone.  Mugna,  Am.  Jour.  Med. 
Sgi.,  vol.  iv.,  p.  483. 

New  method  of  treating  some  forms  of.     Mackenzie,  Gas.  Med.  Paris., 

1867,  p.  533. 

The  treatment  of  rawness  of  tongue  and  painful  deglutition  in  advanced 

phthisis.     Powell,  Lancet,  11,  25  December,  1868. 

of  18  years'  standing,  cured  by  one  insertion  of  stomach-tube.     Le  Gros 

Clark's  Lectures  on  Surgical  Diagnosis,  etc.,  1870,  p.  243. 

iJpiGLOTTlS. — On  the  anatomical  structure  of,  in  the  new-born.  Maingatjlt 
{Arch.  Gen.,  April,  1829),  Am.  Jour.  Med.  8ci.,  vol.  v.,  p.  189. 

Case  of  attempted  suicide,  with  danger  of  suffocation  from  faUing  down 

of  the  epiglottis.  Houston  {Dublin  Hasp.  Repts.,  vol.  v.).  Am.  Jour. 
Med.  Sci.,  vol.  viii.,  p.  229. 

Loss  of  portion  of  by  gunshot  wound.     Swallowing,  etc.,  good  in  18  days. 

Larrey  (Case  VI,),  Am.  Jour.  Med.  Sci.,  vol.  viii.,  p.  514. 

Loss  of  entire  epiglottis.     Lbid.  (Case  VII.).     Ibid.,  p.  515. 

Polypus  of;  spontaneous  separation.     Syme,  A7n.  Jour.  Med.  Sci.,  AprU, 

1854,  p.  515. 

Anomaly  of,  in  patient  dead  from  cholera.     Epiglottis  entirely  missing, 

without  any  other  physiological  alteration.  No  evidences  were  pre- 
sented during  life.     Eberth  {Yirch.  Arch.,  April,  1868),  Oaz,  hebd., 

1868,  p.  477. 

LuscnKA  (Reichert  and  Du  Bois-Reymond's  J.?'c^. ,  1868,  p.  224)  describes 

and  pictures  a  mus.  hyo-epiglotticus  in  the  ox,  and  a  m.  genio-epiglot- 
ticus  in  man,  which  consists  of  the  genio-glossi  muscles  that  do  not 
terminate  in  the  tongue,  but  pass  backwards  to  the  middle  glosso-epi- 
glottic  ligament. 

Case  of  tuberculosis  in  which  the  epiglottis  became  detached  by  ulcera- 
tion.    Penn.  Hosp.  Rep.,  vol.  ii.,  p.  307. 

•  Complete  loss  of,  from  tuberculous  ulceration.     Tyson  for  Corson,  Am. 

Jour.  Med.  Sci,  AprU,  1869,  p.  397. 

Position  of,  in  the  aged.     G-ibb,  Med.  Times  and  Oaz.,  1869,  p.  293. 

Position  of,  in  the  Jews.     Gibb,  ibid. 

Defect  of.     Eberth  (Virchow's  Arch.,  xliii.  per  Gentbl.  Med.  Wiss.,  April 

13,  1869),  Am.  Jour.  Med.  Sci.,  AprH,  1870,  p.  527. 

Large  sarcomatous  growth  removed  from  under  surface  of.     MACKENZIE, 

Trans.  Path.  Soc.  London,  xxi.,  1870,  p.  513,  cuts. 


544  EEFEEENCES. 

Epistaxis. — Obstinate  case,  after  plugging;   bleeding  from  lachrymal  puncta. 

Am.  Jour.  Med.  Sci.,  vol.  vii.,  p.  526. 
Treatment  of.     Eeveille-Parise.     Am.  Jour.  Med.  8d.,  Jan.  1853,  p. 

231. 
Obstinate  case,  yielding  to  a  mouthful  of  salt.      A7n.  Jour.  Med.  Sci, 

April,  1858,  p.  390. 

And  mode  of  arresting.     Thompson.     Brit.  Med.  Jour.,  1867. 

M.  Fano,  Paris,  ties  four  or  five  pledgets  to  the  nasal  end  of  the  string  of 

the  tampon. 

Tansy  in.     Uhle.     The  Med.  Eecord,  vol.  ii.,  p.  466. 

Erysipelas. — Cases  proceeding  from  eczema  of  nose  ;  cases  proceeding  from 

herpes  of  throat.     Trousseau.  C'Un.  Med.,  Sydenham  So.  Edit.,  vol. 

ii.,  p.  255. 
. Syphilitic  erysipelas,  commencing  in  the  ulcerated  pharynx,  and  spread- 
ing to  the  face  by  the  ears  or  nasal  fossae.     Lancereaux.  Syphilis, 

1869,  vol.  ii.;  p.  130. 
False  Membranes.     Lactic  Acid  in.     Practitioner, '^oy.,\S%S. 
Action  of  chlorates  of  soda  and  potash  on.     Barthez.  Am.  Jour.  MeS. 

Sd.,  Oct.  1858. 
Ozanam,  Ch. — Memoire  sur  les  dissolvants  et  les  desagregeants  des  pro- 

duits  pseudo-membraneux   et  sur  I'emploi  du  brome  dans  les  afEec- 

tions  pseudo-membraneuses.     Paris,  1869. 
Fistule  of  Larynx. — Fistulous  opening  of  larynx.     Operation.     Cooper, 

Am.  Jour.  Med.  8d.,  vol.  i.,  p.  467. 
Fistulous  ulcer  in  front  of  larynx.     Watson,  {Am.  Med.  Times,  June  2, 

1860) ;  Am.  Jour.  Med.  8d.,  July,  1860,  p.  279. 
Fall  von  angeborner  Halsfislet.    Koca,  M&natsdir.  f.  6eb.,  March,  1867, 

p.  161. 
Hamilton's  10th  case  of  bursal  tumors.     N.  T.  Med.  Jour.,  Jan.,  1870, 

p.  54. 

Dr.  J.  H.  Pooley's  case.     Ibid.,  p.  55. 

Follicular  disease  of  pharynx  at  same  time  with  acne,  showing  simultaneous 

inflammation  of  follicles  of  skin  and  mucous  membrane  of  pharynx ; 

due,  in  this  case,  to  debility.     Jour.  Gut.  Med.,  Sept.,  1870,  p.  132. 
Forceps. — Modification  of  Cuzco's  straight,  curved  for  tracheal  tube;  with 

chain  joints,  etc.,  for  oesophagus;  with  cuts.     Bid.  Oen.  de  Therap., 

May  15,  1869;  also  Med.  Times  and  Qaz.,  June  19,  1869,  p.  672. 
Foreign  Bodies  in  Air-Passages.— Death  of  Anacreon  and  Pope  Adrien. 

"La  morte  du  poete  Anacreon  a  eta  occasionee,  parait-il,  par  1' arret 

d'un  pepin  de  raisin  dans  I'un  des  ventricules ;   et  celle  du  pape  Adrien 

par  une  mouche  qui  s'etait  logee  dans  le  meme  endroit  du  larynx." 

MouRA,  L'acte  de  la  Deglutition,   son  Mecanisme.   Paris,  1867,  p. 

14. 
— —External  use  of   tobacco  in.     G-odman,  Am.  Jour.  Med.  Sd.,  vol.  ii.,  p. 

480. 
Bone  lodged  for  48  days  in  the  trachea  of  an  infant.     Stabb,  Am.  Jour. 

Med.  Sd.,  vol.  vi.,  p.  251. 


EEFEEElSrCES.  545 

Foreign  Bodies  est  Am -Passages. — Coin  in  broncliia  remaining  ten  years 
before  producing  death.     A)n.  Jotir.  Med.  Soi.,  vol.  vi.,  p.  518. 

Bone   in   bronchia  producing  pulmonary   abscess.     Autopsy.     Gilkoy, 

Edinb.  Med.  and  Surg.  Jour.,  April,  1831  ;  Am.  Med.  Jour.,  vol.  viii., 
p.  513;  also  Broussats  (Case  LIII.),  chronic  phlegmasise. 

A  practical  treatise  on  foreign  bodies  iu  the  air-passages.     Prof.   S.  D. 

Gross,  Philadelphia,  1854. 

A  grain  of  coffee  fatal  after  remaining  3  J  years.     Pepper,  Am.  Jour. 

Med.  ScL,  April,  1855,  p.  563. 

Suffocation  from  food  in  rima.     Porter,  Dub.  Med.  Press,  Feb.  9,  1859. 

A771.  Jour.  Med.  ScL,  April,  1859,  p.  563. 

Eegurgitation.     Experiments  of  Engel  ;  case  of  death  from  this  cause. 

Could  it  not  have  been  a  post-mortem  occurrence  ?  Wbch.  d.  Zeits.  d. 
g.  A.  Wien,  1866,  No.  31 ;  Qaz.  Med.  Strasbourg,  1867,  p.  233. 

T.  Bertholle,  Des  corps  etrangers  dans  les  voies  aeriermes.     Memoire 

couronne  par  1' Academic  Imperiale  de  Medeciue.  Delahaye,  Paris, 
1867. 

Merkel's  Bericht  iiber  Laryngoskopie.     ScJimidPs  Jalirb.,  Bd.  138,  No. 

5,  p.  230. 

Plate  with  3  artificial  teeth  as  a  foreign  body  in  the  larynx.     Recognized 

and  removed  by  laryngoscopy.  Oertel,  Berl.  Klin.  TFt>cA. ,  iv.  11, 
1867. 

Expectoration  of  a  Mioie  ball.      Gaz.  hebd. ,  1867,  p.  528. 

Transactions  Indiana  State  Med.  So.,  1867,  p.  70.     Weist. 

Regurgitation  of  chyme.     Death.     Parrot,   Gaz.  hebd.,  1868.  p.  489  ; 

also  Bmiking's  Abst.,  1869,  p.  83,  hiOTO-VVnion  Med.,  1868,  No.  91. 

Bone  removed  from  larynx  by  aid  of  laryngoscope.     Schrotter,  Mediz. 

Jahrb.,  xv.  Bd.,  1.  Heft,  1868,  p.  61. 

300  cases.    BouRDrLLAT,  La  Tribune  Medicale,  March  29,  1868,  p.  305 ; 

Gaz.  Med.  de  Paris,  1868,  pp.  94,  121,  125,  180,  212. 

Phenomenes  morbides  simulant  la  phthisie  pulmonaire  tuberculeuse ;  ces- 

sation des  accidents  et  guerison  complete  a  la  suite  d'une  vomique  et 
rejet  du  corps  etranger.  Laborde,  Gaz.  Med.  Pans,  1868,  No. 48, 
p.  701. 

Treatment.     Du  traitement  des  corps  etrangers  des  voies  aeriennes.      An 

extract  from  the  Dictionnaire  Encyclopedique  des  Sciences  Medicales. 
G-TJYON,   Bulletin  Gen.   de  TJierapeutique,   Jan.   15,  1869,  p.   15.     A 
valuable  article  and  reliable  resume,  of  which  the  following  notes  will 
show  its  desert  of  perusal.     Aetius  seems  to  have  been  the  first  to 
have  transmitted  precepts   on  this   point.     L' agitation,  les   efforts 
I'expiration  violente  qui  en  resultent  aurait  pour  effet  habituel  de 
chasser  de  corps  etrangers  au  dehors  (Dalechamps,    Chir.  Frang. , 
cap.  xxxii.,  p.  130;  annot.   A.  Pare,  t.  ii.  p.  443;  edit.  Malg.  Hevin 
mem.  cit.,  p.    436).      Sternutatories  and  syrups  recommended   by 
Fabrice   de   HUden.     Cases  not  influenced  by  position   of  Brodie 
Lenoir,  Duncan,  Beneys  (Malgaigne  ;  Journ.  de  CMrurg.  t.  iii.,  pp.  51 
55,  83;  Rev.  Med.  Chir.,  t.  xi.,  p.  101);  Hasford  {Rev.  Med.   Chir 
35 


546  EEFEEENCES. 

t.  vii.  p.  362),  Dupuytren,  t.  vi.,  p.  303.  Note  of  R.  Benoit  {Qaz. 
Jlfed,  1855,  p.  38).  In  1644  Frederic Monavius  recommended  trache- 
otomy. Theophile  Bonet  and  Willis  soon  had  an  opportunity,  but  did 
not  approve  of  the  operation.  The  autopsy  revealed  how  readily  it 
might  have  been  done,  etc.  (Bonet,  de  affectu  pectoris,  lib.  i. ,  obs.  1 ; 
Willis,  Pharmaoeutica  ratianalis,  Oxford,  1673).  Operation  performed 
(J.  Ph.  Verduc,  Pathol,  de  Chir.,  t.  ii.,  p.  849,  Paris,  1710).  (Heister, 
Inst,  de  Ghir.,  t.  iii.,  p.  449.)  (HaUer,  Opusc.  patlwl.,  Obs.,  7.)  (Wend, 
Hist,  de  la  tracMotomie,  Breslau,  1774.) 
FOKEIGN  Bodies. — Ueber  fremde  Korper  in  den  Luftwegen,  mit  bes.  Bezieh. 
auf  eiuen  Fall  von  giiicklicher  Genesung  nach  langerer  Anwesenheit 
etnes  Pflaumensteins  im  1.  Bronchus.  Inaugural  dissertation.  Ed- 
w^ARD  HoLTZ,  Stralsund. 

Des  sangsues  considerees  comme  corps  etrangers  vivant  dans  les  voies 

aeriennes,  et  en  particulier  dans  le  larynx.  Eidreau.  Several  obser- 
vations.    Gaz.  Med.  de  V Mgerie,  1869,  Nos.  1,  3,  et  seq. 

Eemoval  of,  with  aid  of  laryngoscope.     Fieber,    Wien.  Med.    Woch, 

xix.,  86. 

Eegurgitation.     Eesume  of.     Foville,  Arch.  Gen.  de  Med.,  July,  1869. 

Eutfernung  eines  fremdes  Korpers  aus  d.  Larynx  mit  Hiilfe  d.  Kehlkopf- 

spiegels.     Fieber,  Wien.  Med.   Woch.,  xix.  86. 

Impaction  of  a  penny  in  larynx  for  six  years.     Laryngoscopic  diagnosis 

and  successful  removal.  Petrie,  Brit.  Med.  Jour.,  Aug.  30,  1870, 
p.  186. 

Goldpiece  ta  larynx  six  years.     Detection  with  laryngoscope  and  removal 

with  forceps.  Cameron,  Liverpool  Med.  and  Surg.  Rep.,  iv.,  p.  180, 
October,  1870. 

Knife-blade  in  chest  twelve  years.     Spontaneous  expulsion.     Snyder, 

Chicago  Med.  Ex.,  July,  1870;   The  Med.  Times,  Dec,  1870,  p.  86. 

Pebble  moving  from  right  to  left  bronchus.     Death  in  two  months.     Au- 

topsy. Le  Gros  Clark,  Lectures  on  Surgery,  London,  1870,  p.  237. 
Aliments. — Food  found  in  bronchi  after  death,  six  hours  after  injury 
to  head  by  fall  of  earth,  etc.  Le  Gros  Clark,  Lectures,  etc.,  p.  335. 
— —  Suicidal  sufEocation  by  cotton  wool  in  pharynx  and  larynx.  Mackenzie, 
Trans.  Path.  So.  London,  1870,  p.  43.  See  similar  case  in  Giinther's 
Lehre  von  den  blutigen  Operationen. 

Shawl-pin  in  lungs  for  four  years.     Herrick,  Boston  Med.  and  Surg. 

Jour.,  Feb.  16,  1871,  p.  108. 
—. —  Canula  in  bronchus  four  years.     Masing  {St.  Petersb.  Med.  Zeit.  Chr., 
1869,  Heft  7),  translated  by  Tuck,  Boston  Med.  and  Surg.  Jour.,  Feb. 
33,  1871,  p.  128. 

Suffocation  mistaken  for  apoplexy.     Barnes,  Brit.  Med.  Jour.,  March 

25,  1871,  p.  313.  A  man,  set.  67,  was  accidentally  choked  while  eat- 
ing an  orange.  Some  time  previously  he  had  had  an  apoplectic  fit, 
and  the  impression  of  his  friends  was  that  he  had  been  seized  with 
another.  On  opening  the  trachea,  the  piece  of  orange  was  found 
completely  blocking  up  the  entrance  into  the  larynx. 


EEFERElSrCES.  547 

Fbactuke  of  Lakyns. — Cure;  Penna.  Hospl.,  Med.  Exam.,  April  25,  1838. 

GiBB.      Brit.   Am.  Jour.  &  Provincial  Med.  &  Surg.   Jour.,  1851,  p. 

20. 

Fore  and  Wood.      Western  Lancet,  and  N.  Y.  Jour.  Med.,  vol.  xv.,  p. 

152. 

Taylok's  Medical  Jurisprudence,  p.  756. 

Hamilton's  Treatise  on  Fractures,  1855. 

Wilson.  Edinb.  Med.  Jour.,  1855-6,  p.  289. 

Keiler,  ibid.,  p.  527. 

with  fractture  of  hyoid,  &c.     Tracheotomy,  recovery.     Sawyer,  Am. 

Jour.  Med.  Sci.,  Jan.  1856,  p.  13. 

MoTJiLLE.    Recueil  de  memoir  en  de  med. ,  de  cliir. ,  et  de  pTiarm.  militaires. 

3   serie,  1861,  p.    224.    Fracture   of  larynx  with,  large   penetrating 
wound.     Tracheotomy,  cure,  with  movability  of  larynx. 

On  fractures  of  the  larynx,  and  ruptures  of  the  trachea.     Wii.  Hunt. 

Am.  Jour.  Med.  Sci.,  AprQ,  1866,  p.  378. 

Handbuch  der  Lehre  von  den  KJiochenbruchen,  Zweiter  Theil.  i.  Liefe- 

rung.     E.  GuRLT,  Hamm.,  1864. 
Wales.     Ain.  Jour.  Med.  Sei.,  1867,  No.  i.,  p.  269. 

Hamilton,  The  Medical  Record,  vol.  i.,  p.  507;  Am.  Jour.  Med.  Sci., 

April,  1867,  p.  567. 

Fraktur  der  cartilago  cricoidea.     Hautemphyseni.     Tod.     Hoggmark  ; 

Eygea,  November,  1867.  ScJimidfs  Jahrb.,  No.  ii.,  1868.  Bd.  40,  p. 
192. 

Bruch  d.  Kehlkopfes ;   Hautemphysem ;   Dyspnoe,  Tracheotomie ;    Tod 

durch  mediastinales  Emphysem,  und  sekundare  Perikarditis.   ^Yiell. 
Med.  Woch.,  xviii.  15. 

CEdema,  tracheotomy,  cure.     Maclean,  Union  Med.  Oironde,  April  28, 

1868,  p.  260. 

Historical  and  critical  Summary  of  Fractures  of  Larynx.     Henocque. 

Gaz.  hebd.,  1868,  Sept.  25  and  Oct.  2. 

Quelques  considerations  sur  les  fractures  traumatiques  du  larynx,  et  lear 

traitement.     Fredet,  Paris,  1868. 

Fracture  of  Larynx.     Death.    Gagnon,  Fredet,  Oaz.  desliop.,  1868,  Nos. 

90,  91 ;  Edinb.  Med.  Jour.,  Jan.  1869,  p.  665  ;  Brit.  &  For.  Med.  GJiir. 
Rei\,  Jan.  1869,  p.  266. 

Traumatic  fractures  of  larynx.     Stokes,  Bub.  Quar.  Jour.  Med.  Sci., 

May,  1869,  p.  307,  with  case  ;  illustrated. 

Homicidal  fracture  of  cricoid  cart.     Pemberton,  Lancet,  May  22,  1869. 

Fracture  du  larynx;  mort ;  autopsie.     Servier,  Gaz.  hebd.,  1869,  No. 

7,  p.  103;  ibid..  No.  14,  p.  222;   Am.  Jour.  Med.  Sci,  July,  1869, 
p.  251. 

Considerations  sur_  les  fractures  du  larynx  et  leur  traitement.     Fredet 

Ehelnang,  Gaz.  Med.  de  Granada,  May  31,  1869.     Bibl.  va.  Bui.  de 
TUrap.,  August,  1869,  p.  129. 

Suicidal  fracture.     Specimen  shown.     Stokes,  Bub.  Quar.  Jour.,  May, 

1870,  p.  503. 


548  EEFEEENCES. 

Fkontal  Smus. — Case  of  disease  of.     Jaeger,  A?n.  Jour.  Med.  Sci,  vol.  v., 
203. 

Case  of  fracture  connected  with,  and  exposure  of  frontal  nerve.     Wells, 

A7n.  Jour.  Med.  Sei,  October,  1857,  p.  553. 
GrALTAJsriSM. — After   tracheotomy  for  croup,  to  prevent    suffocation.      Gas. 
hebd.,  November  22,  1867,  p.  746. 

iu  Aphonia  and   other  laryngeal  affections.     voN  Brthsts.     Die  Laryn- 

goskopie,  &c.     Tubingen,  1867,  p.  234. 

Mackenzie.     On  the  Laryngoscope.     London,  1866,  1869,  1871. 

Mackenzie.     Hoarseness,  loss  of  voice,  &c.     London,  1868. 

G-ALVANO -Cautery. — Turck.     Klinik  derKehlkopfkranikheiten.  Wien,  1866, 

p.  579. 

VoLTOLiNi.     Die  Anwendung  der  Galvanokaustic  im  innem  des  Kehl- 

kopfes  und  Schlundkopfes.     Wien,  1867. 

Galvano-caustische  Schlinge  zur  Behandlung  der  Kehlkopf -polypen.    Ber- 

lin. Klin.  Woeh.,  1869,  p.  27. 

iu  laryngeal  growths,  &c.     SCHNITZLER,  Wochen-blatt.     Wien,  1868,  No. 

43,  p.  393. 

in  lafyngeal  growths.     Prlnz,  L'  Union  Med.  Gironde,  1868,  p.  94. 

YON   Bkuns.      Die  Laryngoskopie  und  die  laryngoskopische  Chirurgie. 

Tubingen,  1868,  p.  244. 

Galvano-caustische    Schlinge    zur  Behandlung   der    Kehlkopf-polypen. 

Berlin.  Klin.  Woch.,  1869,  p.  27. 

in  removal  of  laryngeal  tumors.     Reichel.   Berlin.  Klin.  WocJi.,  No.  51, 

1869.     Practitioner,  March,  1870.     Am.  Jour.  Med.  /Sci,  April,  1870, 

554. 
Bedeutung  der  Galvanokaustik  fiir  die  Entfemung  von  Neubildungen 

aus  dem  Kehlkopf.     Prof.  Bruhl.     Wien.  Med.  Woch. ,  April  2,  1870, 

No.  21,  p.  370. 
Die  Galvano-chirurgie,  oder  die   Galvanokaustik   und  Elektrolysis  bei 

chirurgischen  Krankheiten.     VON  Bruns  ;    Tiibingen,  1870. 
Gargling.—  iltude  du  Gargarisme  laryngien.     H.  Guinier,  Paris,  1868. 
Ueber  erne  neue  Methode  Heilmittel  auf  den  Schlund  und  Kehlkopf  zu 

appliciren.     Meckel,  Memorab.,  Dec.  12,  1868,  p.  202. 
GoiTRE.^Carbonate  of  Soda  in.    Htjpeland,  Am.  Jour.  Med.  Sci.,  vol.  ii. ,  p. 

438. 
Definition  of  bronchocele.     Cases,  etc.     Larrey,  J.??z.  Jour.  Med.  Sci., 

vol.  vi.,  p.  516. 

tJber  die  Cystengeschwillste  des  Halses.     E.  Gurlt,  Berlin,  1855. 

in  an  infant  which  lived  but  a  few  hours.     Simpson,  Am.  Jour.  Med.  Sci. , 

July,  1855,  p.  192. 

Exophthalmic;  case.     Am.  Jour.  Med.  Sci.,  July,  1855,  p.  249. 

Exophthalmic;  case.     Banks,  Am.  Jour.  Med.  Sci.,  Oct.;  1855,  p.  527. 

Exophthalmic ;  case.     Taylor,  A^n.  Jour.  Med.  Sci. ,  July,  1S56,  p.  258. 

Suffocating.     BoNNET,  Am.  Jour.  Med.  Sci.,  April,  1856,  p.  493. 

Cysts  of  thyroid  treated  by  cauterization.      Gaz.  hebd.,  Nov.  1,  1867,  p. 

701. 


EEFEEElSrCES.  549 

GoiTEE. — Exophthalmic  ;  -with  gangrene  of  extremities.      Oaz.  Tiehd.,  1867,  pp. 
585,  779. 

Extirpation  of.     Oaz.  Jiebd.,  1867,  p.  141. 

Extirpation  of.     G-REENE,  Am.  Jour.  Med.  Sci.,  1867,  p.  283. 

Epidemic.     Worbe,  Gas.  hebd.,  1869,  p.  699. 

Injections  of  iodiae    in  parenchymatous  bronchocele.     LtJCKE  {Berlin. 

Klin.  Woc7i.,  Dec.  28, 1868) ;  Brit,  and  Foreign Med.-GMr.  Rev.,  1868, 
p.  558. 

Producing  asphyxia  in  a  new-bom  child.  Weight,  41. 6  grammes.  Hecker 

{Mon.  f.  Geburts,  xxxi.,  2  and  3,  1868)  ;  Sohmidfs  Jaliri.,  No.  7, 
1868  :   also,  Le  Mouvejnent  Medical,  1869,  No.  30,  p.  35. 

On  treatment.  Schinzinger  (Congress  of  German  Naturalists  and  Phy- 
sicians, 1868)  ;  Med.  Times  and  Gaz.,  Jan.  30,  1869,  p.  124. 

Treatment  by  cauterization  with  chloride  of  zinc.     Sedillot  ( Gaz.  des 

Mp.,  1868,  No.  45)  ;  Am.  Jour.  Med.  Sci.,  Jan.,  1869,  p.  262. 

Treatment  by  cauterization  with  chloride  of   zinc.     Mackenzie,  Am. 

Jour.  Med.  Sci. ,  April,  1868,  p.  547. 

Same  author,  four  cases.     Trans.  Clin.  So. ,  London,  vol.  i. ,  1868  ;  Am. 

Jour.  Med.  Sci.,  Oct.,  1869,  p.  468. 

Iodide  of  ammonium  in.     WARiNa-CuRRAN,  Med.  Press  and  Circ,  June 

9,  1869. 

Interstitial  injection  of  chloride  of  zinc.     Eichet,  Gaz.  des  Mp.,  July 

24,  1869. 

In  Savoy.     Use  of  iodiae  lozenges,  etc.     Med.  Times  and  Gaz.,  Oct.  23, 

1869,  p.  505. 

With  cancer  of  thyroid.     Aphonia  among  other  symptoms.      Left  lobe 

had  pressed  on  recurrent  nerve,  etc.     Payne,  Med.  Times  and  Gaz., 
Dec.  3d,  1870,  p.  660. 
Exophthalmic.        Chisholm,    Phil.    Med.     Times,    Oct.    15,    1870,    p. 
21. 

Pendulous  pedunculated  bronchocele  successfully  removed.     Blackman, 

Am.  Jour.  Med.  Sci.,  Jan.,  1870. 

A  case  successfully  treated  by  electrolysis  and  subcutaneous  injections  of 

iodiae.     Walttjch,  Med.  Times  and  Gaz.,  Jan.  28,  1871,  p.  96. 

Case  of  removal.     Pancoast,  The  Med.  Times,  April  15,  1871,  p.  257. 

Three  cases  successfully  removed.     Greene,  Am.  Jour.  Med.  Sci.,  Jan. 

1871,  p.  80. 

Case  of  bronchocele  causing  urgent  dyspnoea.      Operation.      Eecovery. 

Hayes.  In  this  case  the  operation  consisted  in  dividing  the  tense  cer- 
vical fascia  over  the  tumor,  and,  on  another  occasion,  the  sterno-hy- 
oid  and  sterno-thyroid  muscles,  exposing  the  gland,  and  aflEording  such 
relief  that  the  patient,  a  female  set.  18,  could  lie  down  with  perfect 
comfort.  The  tumor  gradually  diminished  from  the  size  of  half  a 
fair-sized  melon  to  that  of  a  very  small  orange. 

Grovtths  in  the  Larynx. — Case  of  sudden  death  from  obstruction  of  larynx, 
caused  by  a  tumor  deemed  syphilitic.  Senn,  1826.  {Journ.  de  Pro- 
gres,  vol.  xvii. )  ;  Am.  Jour.  Med.  Sci.,  vol.  vi.,  p.  223. 


550  EEFEEElSrCES. 

Growths  in  the  Larynx. — Case  of  sudden  death  from  polyp.     Dtjpuytren, 

Ain.  Jour.  Med.  Sci.,  vol.  vi. ,  p.  518. 

Histoire  des  Polypes  du  Larynx.     Ehrmann,  C.  H.     Strasbourg,  1850. 

Spontaneous  separation  of  a  polypus  of  the  epiglottis.     STiiE,  Month. 

Jour.  Med.  Sci.,  Oct.,  1853. 
On  the  surgical  treatment  of  morbid  growths  within  the  larynx.    GrUR- 

DON  Buck,  Trans.  Am.  Med.  Ass'n.,  Philadelphia,  1853. 

Cancer  of  larynx.     Paget.     Lectures  on  tumors.     London,  1853,  p.  428. 

discovered  after  death.     Geoghegan,  Atn.  Jour.  Med.  Sci,  Jan.,  1855. 

p.  247. 
On  the  surgical  treatment  of  polypi  of  the  larynx ;  and  oedema  of  the 

glottis.     Horace  Green,  K-  Y.,  1859. 
Die  erste  Ausrottung  ernes  Polypen  in  der  Kehlkopfshohle  durch  Zer- 

schneiden  ohne  blutige  Eroiinung  der  Luftwege,  etc.     voN  Bruns, 

Tiibingen,  1862. 
Polypes  du  larynx  et  de  la  trachee-artere  reconnus  au  moyen  du  laryngo- 
scope et  extirpes  jiar  les  voies  naturelles.     Ozanam,  Gaz.  Med.  Paris. 

Acad,  des  Sc,  Seance  Juin  22,  1863,  sheet  441. 

On  the  throat  and  windpipe.     Gibe,  London,  1864. 

Die  Laryngoskopie  und  die  laryngoskopiache  Chirurgie.    Mit  etnem  Atlas 

von  acht  Tafeln.     Victor  von  Bruns,  Tiibingen,  1865. 
Laryngoscopal  surgery  illustrated  in  the  treatment  of  morbid  growths 

within  the  larynx.  L.  Elsberg,   Philadelphia,   1866.    Being  the  prize 

essay  to  which  the  American  Medical  Association  awarded  the  gold 

medal  for  MDCCCLXV. 

Operative   Bezeigungen.     Use   of    a   silver  lancet.     Merkel,   Deutsche 

.  mirdk,  1866,  p.  262. 
Division  of  larynx  to  remove  foreign  growths.     DURHAM,  Ouy''s  Hosp. 

Rep.,  1866. 
TTIinik  der  Krankheiten  des  Kehlkopf es  und  der  Luftrohre,  etc.     Ludavig 

TuRCK,  Wien,  1866. 
Clinical   study  of  congenital   and    infantile.      DUFOUR,    March,    1866, 

p.  273. 
fitude  sur  les  Polypes  du  Larynx  chez  les  enfants,  et  en  particuher  sur  les 

polypes  congenitaux.     A.  Causet,  Paris,  1867. 
Die   Anwendung    der   Galvanokaustik  im  innem   des   Kehlkopfes  und 

Schlundkopfes,  etc.     E,.  VoLTOLiNi,  Wien,  1867. 
Extirpation  of  iibro-epithelial  neoplasm  from  vocal  cords.     Cutter,  Am. 

Jour.  Med.  Sci. ,  Jan. ,  1867,  p.  138. 
Eemoval  of  fibro-plastic  tumor  from  vocal  cords.     Olliver,  Am.  Jour. 

Med.  Sci.,  July,  1867,  p.  115. 
- —  On  tumors.  .   Gas.  held.,  1867,  p.  304. 
Extirpation  of  tumors.     Gaz.  hebd.,  1867,  p.  414,  634. 

Fibrous,  removed  after  tracheotomy.     Eoquefous,  Gaz.  hehd.^  October 

4,  1867,  p.  634. 

Eemoval  of  tumor.     Cutter,  Boston  Med.  &  Surg.  Journ.,  September, 

1867. 


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Laryngeal.      Gaz.  hebd.,  1867,  p.  655. 

Galvano-caiitery  in,  with.  case.     Prin'tz,  ArcJi.  der  Reilkunde^  1867. 

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dans  la  premiere  enfance.     DUFOUR,  Paris,  1867. 

Expose  d'un  cas  de  polypes  multiples  du  larynx,  traites  et  gueris  par  la 

laryngotomie  thyreo-hyoidienne.     FoLLEsr,  Paris,  1867. 

Extirpation  of  laryngeal  polyps.     FouRNiE,    Gaz.   des  Mp.,  1867,    24. 

Ueber  Larynxgeschwiilste.      Vircli.  ArcJi.^  xxxviii.,  2.  p.  202. 

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bei  einem  3  jahr.  Knaben.      Virchoio's  Arch.,  xliii.,  1.  p.  129. 

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Polyp,  onlig.  ary-epig.     Stork,  Woch.  d.  Wien.  Qesell.,  1868,  Nov.  p.  417. 

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Beitrag  zur  Behandlung  der   Kehlkopfneubildungen.     NxIYRATIL,  ten 

cases,  two  of  them  bands  across  cords — very  interesting.     Berliner 
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Removal  from  ventricle,  after  section  of  thyroid  cart.     G-uton,  Gaz. 

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Removal  from  ventricle  after  laryngotomy.     Krishaber,  Gaz.  des  hop. , 

103. 

Laryngotomy  for.     MoiJRA,  Gaz.  des  hop.,  109. 

Navratil.      Removal   of  polyp    after  section    of  larynx    Wien.  Med. 

Woch.,  xix.  72. 

Removal  of  polyp  from  ventricle  after  section  of  thyroid  cart.   Tartivel, 

Union,  103. 

Syphilitic  tumor  in  upper  part  of  larynx.     WiLKS,  the  syphilitic  affections 

of  the  internal  organs,  with  plate.    Quoted  in  Lanceraux  on  Syphilis, 
1869,  vol.  ii.,  p.  4. 

Removal  of,  by  laryngotomy.     Atlee,  Am.  Jour.  Med.  Sci.,  April,  1869, 

p.  378. 

Removal  of  tumors,  two   cancroids.      Tobold,  Deutsche  KUnik,   1869, 

p.  28. 

Case  operated   on  by  Stork  with  a  tonsillotome-like   ecraseur,    after 

failure  by  himself,  Bruns,  Tilrck,  and  others.     Wien.  Med.  Woch.,  1869, 
No.  40,  p.  676.     The  wire  had  not  cut  through  growth,  but  broken. 

Utihty  of  laryngotomy  in  removal  of  growths.    Four  cases.     Balassa, 

Wien.  Med.   Woch.,  Nov.  11th,  1869. 
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552  EEFEEEINTCES. 

Allg.  Med.   C-Ztg.,  January  19  &  26,  1869;  also  Med.  Jahrb.,  <&c., 
Wien.,  1869,  No.  2.     Cuts.     A  fatal  case  recorded. 
Growths  in  the  Larynx. — Case  of  extirpation  of  an  epithelioma  by  externa 
incision  of  larynx.  Navratil,  Wien.  Med.  TFbc^.,  1869,  March  17.  Cuts. 

Schleimpolyp  im  Kehlkopf .  Entfemung  durchLaryngofission.  NAVRATIL, 

Wien.  Med.  WocJi.,  1869,  September  8,  72,  p.  1201.     Cuts. 

Extirpation   eiaes  Kehlkopfephitbelioms   durch   Laryngofission.      Nav- 

ratil, Wien.  Med.   Woch.,  1869,  p.  365.     Cut. 

Extirijation  of  a  tumor  from  vocal  cords.     Johnson,  Med.  -  Ghir.  Trans. , 

li.,  p.  178. 
_ Cases  of  extirpation  of  growths  from  larynx.   ToBOLD,  Berl.  Klin.  Woch., 

vi.  3,  p.  31,  4,  p.  42,  1869. 
A  membranous  band  beneath  vocal  cords.      Schrotter,    Wien.  Med. 

Woch.,  April  3,  1869,  p.  449. 

Laryngeal  poylp  found  after  death  in  a  case  of  diphtheritic  croup  for 

which  tracheotomy  had  been  performed.     Bergeron,   Qaz.  heid., 

1869,  p.  253. 
A.  contribution  to  the  Surgical  therapeutics  of  the  air-passages.     Cases. 

Removal  of  a  morbid  growth  from  the  cavity  of  the  larynx  by  laryngo- 
.  tracheotomy,  subsequent  escape  of  a  hard  rubber  trachea  tube  into 

the  right  bronchus,  and  its  removal  by  operation.  Buck,  Trans.  N.  T. 

Acad.  Med.,  vol.  iiL,  partx.,  New  York,  1870. 
•  Contributions  to  practical  laryngoscopy.     Four  cases  of  morbid  growths 

within  the  larynx.     Ruppaner,  N.  Y.  Med.  Jour. ,  January,  1870,  p. 

337.    Cuts. 

Polype   du  larynx.      Extraction  par  les  voies  naturelles..      Guerison. 

Patient  14i  years.     Krishaber,  Oaz.  desMp.,  1870,  p.  147. 

of  animals.     Mackenzie,  Med.  Times  &  Gaz.,  March  11,  1871,  p.  293. 

Laryngologische  Beitrage.     E.  Nayratil,  Leipzig,  1871. 

Essays  on  Growths  in  the  larynx.    Morell,  Mackenzie,  London,  1871. 

Thyrotomy  for  the  removal  of  laryngeal  growths.     E.  Cutter,  Boston, 

1871. 

Contributions  to  Practical  Laryngoscopy.      A.  Ruppaner,  second  series, 

N.  Y.,  1871. 

Contributions  to  laryngoscopic  Surgery.     Carlo  Labus,   Oaz.  Lomb., 

1871,  30. 

Excision  of  a  papilloma  from   the  right  vocal  cord.     Jo.  M.  Oertel, 

BUitter  far  Heilwiss.,  1871,  ii.,  4.  5. 
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Hygroma.  — On  a  peculiar  form  of  congenital  tumor  of  the  neck.     Hawkins, 

Med.-Chir.  Trans  ,  1839,  p.  231. 
.  Des  Kystes  du  Cou.     Voillemier,  Paris,  1851. 

Das  angeborene  Cysten-Hygrom.  des  Halses.     Gurlt,  iiber  die  Cysten- 

geschwiilste  des  Halses.     Berlin,  1855. 

Die  Scheimbeutel  Hygrome  der  Regio  thyreo-hyoidea.     GiiRLT,  Ibid. 


EEFEEEXCES.  553 

Hygroma. — Das  Hygroma  hyo-epiglotticum.     VircTi.  Arch.,  1864,  1  &  2,  p.  234. 

Super-larrngeal  encysted  tumors.     Hamilton,  Elsberg,  Pooley,    The 

Medical  Record,  February  15,  1870. 

of  hyoid  bursa.     Mackexzie,  case  7  or  8  years'  duration.     Difficulty  of 

swallowing  and  breathing.  Cyst  punctured  and  seton  introduced ; 
produced  laryngeal  irritation,  but  cured  patient ;  refers  to  Hamilton 
and  Elsberg,  bx  Medical  Bscord.,  February,  1870.  Med.  Times  &  Gaz., 
Febi-uary  11,  1871. 

Hyoid  Boxe. — Fracture  ;  oedema,  tracheotomy,  artificial  respiration,  cure. 
Ara.  Jour.  Med.  Sci.,  January,  1855,  p.  71. 

EsTFLrENZA. — Atmospheric  changes  during  prevalence  of  influenza  in  Eng- 
land. HixGESTOX  (London  Med.  Gaz.,  August,  1831),  Am.  Jour.  Med. 
Sci.,  vol  ix. ,  p.  536. 

State  of  dew-point  in  connection  with  epidemic  at  Philadelphia,  in  1831. 

Am.  Jour.  Med.  Sci.,  vol.  ix.,  p.  541. 

As  it  occurred  in  Burke  Co.,  Ga.,  in  1831-2.    Baldwin,  Am.  Jour.  Med. 

Sci.,  vol.  XL,  p.  33. 

On  the  influenza  or  epidemic  catarrhal  fever  of  1847-8.     Peacock,  Lon- 

don, 1848. 
•  Annals  of  Influenza.     Thompson,  Sydenham  So.,  London,  1862. 

Remarks  on  the  epidemic  influenza  of  1861  and  of  1863.  etc.     Levick, 

Am.  Jour.  Med.  Sci.,  January,  1864,  p.  65. 

Sydenham  So.  Bienn.  Retrosp. ,  1867-8,  p.  66. 

Clinical  lecture  on.     Jones,  Brit.  Med.  Jour.,  July  23. 1870,  The  Medical 

Record,  v.,  p.  374. 
Inhalation. — On  inhalation.     Beigel,  1866. 
Apparate  filr.     F.  Fieber,  Wien,  1865,  1866. 

Die  Behandlung,   etc.,   Hals  und   Lungenleiden   durch  Einathmungen. 

SiEGLE,  Stuttgart,  1864. 

Die  Inhalations-Therapie.     Lewin,  Berlin,  1865. 

Behandlung  des  Croup  und  der  Diphtheritis  mittelst  Zinnober  Inhala- 

tionen.      Wien.  Med.  WocJi.,  1869,  1.  p.  10. 
Insufflation. — Of  nitrate  of  silver  in  laryngitis.     Ebert,  Am.  Jour.  Med. 
Sci.,  Oct.  1855,  p.  515. 

Instrument  for,  combined  with  tongue -depressor,  illustrated.     G-elle, 

Gaz.  held.,  1869,  No.  10.  p.  153. 

do.  do.     MiLLOT  (cut),  Gaz.  Med.,  Paris,  1867,  p.  722. 

Larynx,  Laryngoscopy,  etc. — On  the  larynx  and  trachea.  Porter,  London, 

1837. 

On  the  larynx  and  trachea.     Ryland,  London.   1837. 

Case  of  laryngitis,  with  oedema  of  lungs  as  well  as  of  larynx.     ANN  AN, 

Am.  Jour.  Med.  Sci.,  July,  1841,  p.  103. 
Laryngeal  gymnastics  in  ulceration  of  lai-ynx.     Trousseau,  Am.  Jour. 

Med.  Sci.,  July,  1854,  p.  229. 
Aphonia,  dyspnoea,  etc.,   in  laryngitis,   ordered  to  swallow  snow  ;   voice 

regained  in  a  few  hours,  etc.      Parks,  Am.  Jour.  Med.  Sci. ,  April, 

1854,  p.  360. 


554  EEFEEENCES. 

Lakynx,  Laryngoscopy,  etc. — Labor  during  progress  of  laryngitis ;  laryngo- 

tracheotomy ;  recovery  ;  voice  weak.     Lindekmann,  Am.  Jour.  Med. 

Sci.,  Oct.,  1856,  p.  389. 
Der  Kehlkopfspiegel  und    die    Methode    seines    G-ebrauches.     TtKCK, 

Wien,  1856. 
Der  Kehlkopfspiegel  und  seine  Verwerfchung,  fur  Physiologie  und  Medizin. 

CzERMAK,  Leipsig,  1860. 

Du  laryngoscope  au  point  de  vue  prat.     Fauvel,  Paris,  1861. 

Die  Keblkopfkrankheiten.     RUHLE,  Berlin,  1861. 

Sore-throat  and  the  laryngoscope.     James,  London,  1861. 

Clinical  researches  on'different  diseases  of  the  larynx,  trachea,  and  pha- 
rynx examined  by  the  laryngoscope.     Turck,  London,  1863. 
£tude  prat,  surle  laryngoscope  et  sur  I'application  desremedes  topiques, 

etc.     FouRNiE,  Paris,  1863. 
Klinik  d.  Krankheiten  d.  Kehlkopfes  u.  d.  angrenzenden  Organe.     Lewin, 

Berlin,  1863. 
Die  Pharyngoskopie  und  Rhinoskopie,  etc.     Voltolini,  DentscJie  Klinik 

10,  1863. 
Die  Laryngoskopie  u.  ihre  Verwerthung  f .  d.  arztl.  Praxis.    Semeleder, 

Wien,  1863. 

Laryngoscopal  medication.     Elsberg,  N.  Y.,  1864. 

Die  Krankheiten  des  Kehlkopfes.     Batjmgartker,  Freiburg,  1864. 

Essai  sur  la  laryngoscopie  et  de  la  rhinoscopie.   G-uillaume,  Paris,  1864. 

Traite  pratique  de  laryngoscopie  et  de  rhinoscopie.    Moura,  Paris,  1865.. 

Die  Laryngoskopie,  etc.     VON  Bruns,  Tiibingen,  1866. 

Merkel's  review  (an  excellent  article),  SchviicWs  Jahrb.  cxxxiii.  p.  337, 

cxxxiv.  p.  99,  cxxxvii.  p.  225. 
Apparat  zur  laryngoskopischer  Demonstrationen.  Bese,  Deuisclie  Klinik.^ 

1866.  15. 

Rhinoscopy   and   laryngoscopy.       Semeleder,   translated   by   Caswell, 

.  New  York,  1866. 

The  Laryngoscope,  etc.     Johnson,  London,  1867. 

— —  Specukim  for;  Robert  et  Collin,  Oaz.  hebd.^  1867,  p.  121  ;  Oaz.  Med. 

Paris,  1867,  p.  127. 
Ether  in  exudative  laryngitis.    LIVINGSTON,  Am.  Jour.  Med.  Sci.,  April, 

1867,  p.  376. 

Case  of  laryngitis  produced  by  administration  of  Calomel.     Locking, 

Lancet,  Oct.  24,  1868. 
Chronic  diseases  of  larynx.     ToBOLD,  translated  by  Beard,  New  York, 

1868. 

Laryngoscopy  and  rhinoscopy.     Ruppaner,  New  York,  1868. 

Fall  von  Laryngitis  mit  Nekrose,  nach  Typhoidfieber.    Broen,  Press.  Med. 

xxi.  21. 
-^ —  Tubercular  affections  of  larynx.  Prinz,  Arch,  der Heilkunde,  1868,  No.  5. 
Einige  Bemerkungen  zur  Laryngoskopie  und  laryngoskopischen  Chirurgie. 

Waldenbukg,  Berlin  KUn.  Woc/i.,  1868,  No.  51. 
Oliver's  laryngoscope,  Boston  Med.  &  Surg.  Jour.,  Oct.  8,  1868. 


EEFEEENCES.  555 

Lakynx,  Laryngoscopy,  etc. — De  Cristoporis'  laryngoscope,  Annali  Uni 
di Med,  Oct.,  imS. 

De  remploi  du  speculum  laryngien  dans  le  traitement  de  Tasphyxie  par 

submersion,  etc.  Laboydette,  Paris,  1868 ;  reviewed  favorably  in 
Brit,  and  For.  Med.  CJiir.  Bev.,  Jan.  1869,  p.  157. 

Eatjvel's  laryngoscope,  for  bedside  use.  Bid.  Gen.   Ther. ,  May,  1869, 

p.  479. 

Lehrbuch  der  Laryngoskopie.     ToROLD,  2d  ed. ,  Berlin,  1869. 

Clinical  notes  on  diseases  of  the  larynx.     Marcet,  London,  1869. 

Instruments.     New  small  forceps  hook  with  thread  holder  for  steadying 

laryngeal  polyps  during  operation ;  also,  a  new  instrument  for  secur- 
ing small  portions  for  microscopic  examination.  SCHROTTER,  Wien. 
Med.  Woch.,  1869,  No.  67,  p.  1126. 

Snare-like     blade    of    tonsillotome.        Laryngoskopische     Operationen. 

Stoerk;   cuts,  Wien.  Med.  Woeh.,  Sept.  29,  1869,  p.  1297. 

Ueber  laryngoskopische  Operationen.     Stoerk,  Wien.  Med.  Wocli. ,  xix. 

78,  79,  80,  91,  92,  1869.       , 

Illuminating  apparatus.     Malachia  de  Christoforis,   Ann.  Univers. 

xxii.  p.  209. 

Extensive  illuminating  apparatus,  oxy-hydrogen  light,  etc. ,  in  London 

Hospital  for  Diseases  of  the  throat ;  patent  chair,  etc. ,  illustrated, 
Med.  Times  &  Gas.,  July  24,  1869,  p.  98. 

Bemerkungen  zur  Laryngoskopie  und  laryngoskopische  Chirurgie,  Berlin. 

Elin.  Wocli.,  v.  51,  1869. 

Appareil  pharyngo-laryngoscopique.  Fauvel's  mirror,  lig"ht,  and  tongue- 
depressor  combined  in  one  apparatus  ;  illustrated.  Le  Mauvement 
Med.,  1869,  No.  20,  p.  240. 

Differential  diagnosis  of  syphilis,  phthisis,  and  cancer  of  larynx.  Mac- 
kenzie, Med.  Times  &  Gaz.,  1869,  p.  505. 

Larynx  in  the  negro.  Gas.  liebd.,  1869,  No.  25,  p.  386. 

Affections  of  larynx  ia  typhoid  fever.   Trousseau  ;  Clin.  Med.,  vol.  II., 

p.  398  et  seq. 

Dangers  from  hemorrhage  into  larynx.     Ueber  d.  durch  Eindringen  von 

Blut  in  d.  Kehlkopf  bedingten  Gefahren.  voN  Nussbaum,  Bayer. 
Aerstl.  Int.  Bl,  1869,  5. 

Larynx  in  progressive  locomotor  ataxy.     Quelques  symptomes  visceraux, 

et  en  particulier  sur  les  symptomes  laryngo-bronchiques  de  I'ataxie 
locomotive  progressive.     F^reol,  Gaz.  liebd. ,  1869,  p.  108. 

Laryngitis  in    typhoid    fever.     De    Broen,    Presse,  Med.,    1869,    xxi. 

21. 

Unusual  appearances  of  larynx  in  two  cases  of  typhoid  fever,  Am.  Jour. 

Med.  Sci.,  April,  1855,  p.  347. 

Perichondritis   laryngeal   following  typhoid   fever.      Gilliard,    Presse 

Mid.,  1869,  xxi.  20. 

Larynx  and  trachea  in  tabes  dorsalis.     Fereol,  three  cases  of  his  own, 

one  of  Cruveilhier,  1825,  and  one  of  Bourdon,  1862.  V  Union,  1869, 
4,  5,  ScJiviidfs  Jahrb.,  18G9,  Bd.  143,  8,  p.  161. 


556  EEFEEENCES. 

Laeynx,  Lakyngoscopy,  etc. — Removal  of  in  dogs.  Successful  experi- 
ments of  CzERNY,  of  Vienna,  Brit.  Med.  Jour..,  June  18,  1870,  p. 
637. 

Laryngo-typhus.      Tracheotomy.      Recovery.     Ulkich,     Berlin.     Klin. 

Woch.,  1868,  No.  45,  ArcJt,.  Gen.,  1870,  Sept.,  p.  366. 

(instrument).     Die  Lanzennadelspritze  zur  Function  und  Transfusion, 

beim  Scheintod  und  in  der  Laryngoskopie.  Bbesgen,  Koln  u.  Leip- 
zig, 1870. 

Laryngo-tracheitis.     Cold-water  treatment.     Die  Behandlung  der  cliro- 

nischenLaryngo-Traclieitis.  Cokdes,  Berlin.  Klin.  Woch.,  Jan.  1870, 
3,  Wien.  Med.  Woch.,  March  12,  1870,  No.  18,  p.  286. 

Sui  Restringimenti  Laryngei..     Massei,  Naples,  1871. 

Local  treatment.     Ueber  die  Wahl  der  Medikamente  bei  der  Lokalthera- 

pie  des  Larynx  und  der  Trachea  {Wien.  Med.  WogJi.,  xx.  58,  59), 
Schmidt's  Bibl,  April,  1871. 

The  use  of  the  laryngoscope.     Mackenzie,  3d  ed.,  London,  1871. 

Laryngotomy  &  Tracheotomy. — Li  tonsillitis.  Extemporaneous  substitu- 
tion of  quills  for  canule.     Am.  Jour.  Med.  Sci.,  vol.  ii.  p.  213. 

for  occlusion  of  larynx,  case  subsequent  to  attempt  at  suicide.     {Edinb. 

Med.  Jour.,  Jan.  1828.)    Am.  Jour.  Med.  Sci.,  n.  p.  214. 

Causes  of  fatal  termination  in  certain  cases  of  bronchotomy.     CuItLEN 

(Edinb.  Med.  &  Surg.  Jour.,  Jan.  1828).  Am.  Jour.  Med.  Sci.,  vol. 
ii.  p.  462. 

Cases  of   Tracheotomy   (Canula  worn  12  years).      Am.  Jour.  Med.  Sci., 

iii.  p.  471. 

in  an  epileptic.     Neill,  Am.  Jour.  Med.  Sci.,  Jan.  1853,  p.  274. 

in  epilepsy.     Radcliffe,  Am.  Jour.  Med.  Sci.,  July,  1853,  p.  217. 

Trach.  in  Laryngismus.      Hall,  Am.  Jour.  Med.  Sci.,  July,  1853,  p.  55. 

T. ,  for   oedema  glottidis  consequent  on  fracture  of  hyoid  bone.     Wil- 

liams, Am.  Jour.  Med.  Sci. ,  Jan.  1855,  p.  71. 

T.,  in  croup.     Statistics  of  Chaillou,  390  cases,  86  cures.     Am.  Jour. 

Med.  Sci.,  July,  1858,  p.  251. 

T.     Brainerd's  method.     Am.  Jour.  Med.  Sci.,  July,  1857,  p.  291. 

Results  in  1249  cases  of  croup  ;  the  recoveries  numbering  294.     Voss, 

N.   T.  Jour.  Med.,  Jan.  1860. 

T.  for  croup,  33  cases.     Bceckel,  Gaz.  Med.  Strasb.,  1867,  p.  295. 

Tracheotomy  in  cynanche  trachealis,  diphtheria,  and  laryngitis.     Haugh- 

TON,  Trans.  Indiana  State  Med.  Soc,  1867,  p.  122. 

BouRDiLLAT  on  tracheotomy.     Gaz.  hebd.,  1867,  p.  540.     Discussion  on 

tracheotomy,  461  (at  6  mos.),  508,  540. 

New  Canules.     Broca's,  Gaz.  7iebd.,  1867,  p.  235. 

Impossibility  of  removing  tube  after  16  mos.     Paris,  Am.  Jour.  Med. 

Sci.,  Jan.  1868,  p.  273. 

T.  in  croup.    Jacobi  on,  67  operations.     A771.  Jour.  Obstet,  May,  1868. 

New  canule  of  Bourdillat,  Gaz.  liebd.,  1868,  p.  154. 

T.  for  croup  consecutive  to  ulcero-membranous  stomatitis,  in  an  infant 

of  23  mos.  ;   cure.     Isambert,  Gaz.  hebd.,  1808,  pp.  330,  348. 


EEFEEENCES.  557 

Lartngotomy  AMD  TRACHEOTOMY.- — With  prolonged  use  of  canula.      Ehr- 
mann, Oaz.  Med.   Strasb..,  1868,  p.  177. 

Statistics  in  French,  hospitals  for  1863.      Oaz.    Med.    Paris,   1868,   p. 

375. 

Barthez  on  results  (concerning  above  cases).     Gaz.  Med.  Paris,  1868, 

p.  448. 

Vacher's  response  to  Barthez  (strictures  on  above).     Oaz.  Med.  Paris, 

p.  466. 

Barthez  replies,  Oaz.  Med.  Paris,  p.  538. 

T.  in  croup  ;  diphtheria  of  wound  ;  cure.     Memm'obilien,  1868,  p.  31. 

Statistics.     Aitken's  Practice,  Am.  Edit.,  1868. 

Laryngo-trach.  in  suffocation  from  drinking  boiling  water ;  cure.     Lan- 

cet, Aug.  33,  1868. 

Some  valuable  remarks  regarding  time  of  operation,  tube,  etc.     Marcet 

&  HiLMAN,  Lancet,  Dec.  13,  1868. 

Faits  cliniques  de  laryngotomie.     Planchon,  Paris,  1869. 

• On  some  of  the  difficulties  and  dangers  of  tracheotomy,    and  the  best 

means  of  obviating  them ;  with  a  description  of  a  new  form  of  tra- 
cheal canula.     Durham,  Practitioner,  April,  1869,  p.  313. 

Cases  of  diphtheria  saved  by  tracheotomy,  and  remarks  on  the  operation ; 

31  cases  operated  on,  11  saved  ;  9  not  operated  on,  all  perished.  Bu- 
chanan, St.  Andrew's  Trans.,  1868,  Am.  Jour.  Med.  Sci.,  April,  1869, 
p.  483. 

See  notice  in  Wien.  Med.  Woch.,  March  17,  1869,  p.  373  of  Pingler's 

Der  einfache  und  diphtheritic  Croup,  etc.     17  years'  observations. 

On  the  management  of  the  tube  when  tracheotomy  is  followed  by  great 

swelling  of  the  neck,  with  a  simple  device  for  introducing  it  readily. 
CouPER,  London  Hosp.  Rep.,  Brit.  &  For.  Med.  Ghir.  Rev.,  July, 
1869,  p.  41.  A  flexible  rod  of  gutta  percha  tapering  to  a  point  is  in- 
serted, and  the  tube  run  down  on  it. 

Billroth  on  the  difficulties  of  tracheotomy  in  children,  etc.  ;  statistics 

of  his  own  cases  and  other  references.  Wie7i.  Med.  Woch. ,  April  3, 
1869,  p.  454. 
Reflexions  sur  I'operation  de  la  tracheotomie  dans  les  cas  de  croup,  mo- 
dification a  apporter  au  precede  ordinaire.  G-uillon,  Bui.  Gen.  Tlier. , 
1869,  p.  367.  He  proposes  a  sort  of  eyelet  of  flexible  ivory,  or  of  lead, 
to  prevent  the  irritation,  etc. ,  produced  by  the  canule. 

Zur  Casuistik  der  Laryngotomie.     Hopmokl,   Wien.  Med.  Presse,  1871, 

xii.  3-6. 

Thyrotomy  for  the  removal  of  laryngeal  growths.   Cutter,  Boston,  1871. 

Mucus. — On  the  movement  of  mucus  in  the  larynx  and  trachea.     Veale, 

Lancet,  July  33,  1871,  p.  181 — left  to  right— diagram. 
Mumps. — In  a  pregnant  woman  in  premature  labor,  followed  by  appearance 

of  same  disease  in  the  infant  34  hours  after  birth.     Am.  Jour.  Med. 

Sci.,  Jan.  1855,  p.  56. 
Nasal  Passages,  etc. — Case  of  larvae  hatched  in ;  also  elsewhere.    Cloquet, 

Am.  Jour.  Med.  Sci,  vol.  ii.  p.  338. 


558  EEFEEETs'CES. 

Nasal  Passages,    etc. — Metastasis  to,  curing  g-astro-meningeal  irritation. 
Jackson,  Am.  Jour.  Med.  Sci. ,  vol.  ii.  p.  229. 

Complete  amaurosis  cured  by  application  of  leeches  to.     Am.  Jour.  Med. 

/Sci.  ,vol.  iv.  p.  231. 

Periodical  hemicrania  terminating  by  tbe  evacuation  of  a  calculus  through 

the  nose.     AxiiANN,  Am.  Jour.  Med.  Sci.,  vol.  v.  p.  204. 

Disease  of  maxillary  sinus  from  blow  on  nose,  etc.     CouPER,  Am.  Jour. 

Med.  Sci.,  vol.  vi.  p.  519. 

Fibrous  tumor  in  the  neurilemma  of  fifth  pair,  mistaken  for  polyp  and 

operated  on.     Greco,  Am.  Jour.  Med.  Sci. ,  vol.  vii.  p.  227. 
Tumeurs  osseuses  sans  connexions  avec  les  os.     FOLLIN,  BvM.  de  la  Soci- 

ete  de  Mologie,  1850-1. 
.  Exostose  ebumee  de  I'os  ethmoide  occupant  toute  la  masse  laterale  droite 

de  cet  OS.     Maisoxneute,  Gaz.  des  Iwp.,  1853,  IS^o.  95. 
Destructive  disease  of  nose,  larynx,  and  trachea ;  with  specimens,  cast 

of  face,  etc.     Jackson,  Am.  Jour.  Med.  Sci.,  Jan.  1853,  p.  99. 
Sarcina  ventriculi  in  coimection  with  disease  of.     Durkee,  Am.  Jour. 

Med.  Sci.,  Jan.  1854,  p.  96. 
Gonorrhoea  of,  from  use  of  handkerchief.     Edwards,  Am.   Jour.  Med. 

Sci.,  Oct.  1857,  p.  531. 
Exostosis  of  left,   and  1.  orbital  foramen.     MoTT,  Am.  Jour.  Med.  Sci. , 

Jan.  1857,  p.  36. 
Foreign  body  retained  upwards  of  twenty  years.     Hats,  Am.  Jour.  Med. 

Sci.,  AprU,  1858,  p.  390. 
Treatment  of  diseases  of,  by  mercurial  cigarettes.     Am.  Jour.  Med.  Sci. , 

April,  1859,  p.  541. 
Obstinate  chronic  discharge  from,  relieved  by  extraction  of  a  carious 

tooth.     Fleischmann,  Brit.  Med.  Jour.,  April  9,  1859. 
Development  of  larvae  of  dipterae  in  the  frontal  sinuses  and  nasal  fossae  of 

man.  at  Cayenne.   Coquerel  {Brit,  ct-  For.  Med.  Chir.  Bev.,  Oct.  1858, 

from  Arch.  Oen.,  May,  1858),  Am.  Jour.  Med.  Sci.,  Jan.  1859,  p.  254. 
Memoire  sur  les  exostoses  du  sinus  frontal.     DoLBEAtr,  Bull,  de  VAcad. 

deMed.,  1866. 

Fracture  of  cartilage  of  septum.     Jarjavat,  Gaz.  liebd.,  1867,  p.  476. 

Removal  of  steel  ring  lodged  in  for  3^  years,  and  discovered  by  the  rhi- 

noscope.     Hickman,  Brit.  Med.  Jour.,  1867. 
. Puing  introduced  into  nostril  and  forgotten  for  13  years.   Brit.  Med.  Jour., 

1867. 
Insects  in,  thence  to  frontal  sinus,  sometimes  necessitating  trepanning 

for  removal.     Gaz.  hebd.,  1867,  p.  814. 
Administration  of  medicaments  by.     Rambert.      TJnion  Med.    Gironde, 

Nov.  1867,  p.  543.     Gaz.  hebd.,  1867,  p.  426. 
Fracture  of  nasal  bones.     Emphysema  of  eyelids  of  left  eye,  caused  by  an 

old  fracture  of  nasal  bones.      Gaz.  des  Mqi.,  1868,  p.  58.  ;  Edinb.  Med. 

Jour.,  Oct.,  1869;  Ranking' s  Ahst. ,  1869,  xlviii.,  p.  140. 
, The  nose.     Its  role  in  questions  of  hygiene.      Union  Med.  Gironde,  1868, 

p.  627. 


EEFEEElSrCES.  559 

Nasal  Passages,   etc. — On  the  nose.     Ure.     Holmes'  Surgery,  vol.  iii. 
Disease  of  nasal  bones  sometimes  gives  rise  to  cerebral  abscess.    Jackson, 

London  Hasp.  Bep.,  vol.  iv.,  1867-8. 
Necrosis  of  cartilages  of  nose,  in  typboid  fever.  Trousseau,  Clin.  Med. , 

vol.  ii. 
Concretions  in  nasal  passages.     Edinh.  Med.  Jour.,  v.,  p.  501  ;  Ally.  Med. 

Cent.-Ztg.,  1868,  No.  88,  p.  733. 
Specnlum  nasi  for.    Duplay,  Mome.  Med.,  1868,  p.  836  ;  Gaz.  liebd.,  1868. 

p.  792. 
Straightening  septum  of  nose.     Instrument  zur  Heilung  der  verkriimmten 

Nasenscheidewand.     Kupprecht,    Wien.  Med.    WocJi.,    1868,  xviii. , 

72. 
Nasal  septum.     Perforation  of,  in  manufacture  of  bichromate  of  potassa. 

Berxard,  Hillairet,  Lailler,  Gubler.    Comment.  Therap.,  G-ub- 

LER,  Paris,  1868,  p.  405. 
Administration  of  food  and  medicine  by  the  nose.     Moxley,  Practitioner, 

April,  1869,  p.  240 ;  Lancet,  March  20. 
Sur  les  resections  sous-periostees  de  la  cloison  nasale.     Chassaignac, 

Gaz.  liehd.,  1869,  No.  24,  p.  380. 
Instrument  for  examining.     Ueber  ein Verfahren  zum  Zwecke  des  Besich- 

tigung  des  vorderen  und  mittleren  Drittheiles  der  Nasenhohle.    Wer- 

THEI3I,  yfien.  Med.  Woch.,  1860,  Nos.  18,  19,  20,  illustrated.     A  sort 

of  Choanoscope ;  a  diagonal  mirror  in  a  tube. 
Syphilitic  affections  of  nose  and  adjacent  parts,  hereditary,  but  not  show- 
ing themselves  until  the  age  of  10,  16,  etc.     Lancereaux  on  Syphi- 
lis, vol.  ii.,  p.  165. 

Des  Osteomes  de  I'organ  de  I'olfaction.     Gaubert,  Paris,  1869. 

Sur  les  tumeurs  osseuses  des  fosses  nasales  et  des  sinus  de  la  face.     Oli- 

TIER,  Paris,  1869. 
Nares.      Occlusion  of  posterior  nares.      Syphilitic  adherence  of  palate 

(save  uvula)  to  pharynx.     Silver,  Med.   Times  and  Gaz.,  1870,  p. 

619. 

Foreign  body  in.     A  sailor,  set.  29,  received  portion  of  a  bursted  gun-barrel 

.  in  frontal  sinus,  Jan.  5,  1864.     Jan.  10,  1870,  a  breech  and  screw  was 

removed  weighing  8  oz.  6  gr.     Subsequently  a  rhinoplastic  operation 

was  performed.     Bartlett,  Brit.  Med.  Jour.,  1870,  p.  704. 
Nasal  Polyps. — Cure  by  saffronized  tr.  opii.     Primus,  Am.  Jour.  Med.  Sci., 

ii.,  p.  218. 
Case  of  gelatinous  polypus  cured  with  Sanguinaria  Canadensis,  after  ex- 
traction had  twice  failed.     Shanks,  Am.  Jour.  Med.  Sci. ,  Oct. ,  1842, 

p.  868. 
and  affections  confounded  with  them.     Cure  by  insufflation  of  tannin. 

Bry.\xt,  La7iGet,  1867,  Feb.  23,  Aug.  24. 
removed  by  tr.  ferri  chloridi.    Maxwell,  The  Medical  Becord,  vol.  iii. ,  p. 

353. 
Cure  by  injection  of  ferri  persulph.     Gardner,  The  Med.  Becord,  1869, 

Feb.  1,  p.  540. 


660  EEFEEENCES. 

Nasal  Polyps. — Removal  of  a  large  nasal  polyp.    Smith,  Med.  Times  and 

Oaz.,  Oct.  2  ;  Brit.  Med.  Jour.,  Nov.  20,  p.  557. 
Polype  glandulairede  la  muqueusenasale.    Repullulation.    Extirpation  et 

cauterization.     Accidents  consecutifs  a  1' operation.     Paralysie  de  tons 

les  muscles  de  I'oeil.     Symptomes  d'empoisonnement  par  la  morphine. 

Moit.  Autopsie.     Botkon,  Le  Mouveftnent  Medical.,  1%Q9,  xix.,p.  231. 
Fibriuous  polypi  from  the  nares.     Sqtjire,   Trans.  PatJt.  So.,  London, 

xxi. ,  1870,  p.  343. 
removed  from  child  9  years  old.     Majrsh,  Trans.  Path.  So.,  London,  xii. 

p.  343. 
Naso-phahtngeal  Polyps. — Polype  fibreux  de  la  base  du  crane.  Nelaton, 

Oaz.  des  Tio'p. ,  1853,  No.  5. 

Polypes  naso-pharyngiens.     MiCHAUX,  Gaz.  des  M]}.,  1853,  No.  13. 

Extraction  sub-  periosteal,  by  anterior  opening  of  sup.  max.     Executed  be- 

hiad  the  everted  upper  lip.     Larghi,  Qaz.  Mtd.  Paris,  1867,  p.  617. 

Michaux,  Qaz.  hebd.,  1867,  p.  361. 

Diagnosis  and  treatment  of  naso-pharyngeal  polyps.     Herrgott,  Gaz. 

desMp.,  1867,  25. 
Treatment  of    naso-pharyngeal  polyps  by    electricity.     Nelaton   AITO 

HiFPELSHEiM,  Union  Mkl.  Gironde,  1868,  pp.  225,  228. 
Return  of,  in  case  operated  on  by  a  new  method  in  Nov. ,  1865.  Legotjest, 

Gaz.  held.,  1868,  p.  685. 
Rapport  sur  une  observation  de  polype  naso-pharyngien  a  embranche- 

ments  multiples.     Thomas,  Gaz.  hebd.,  1869,  1,  p.  13. 
Removed  by  a  new  operation.    Cure.    Bonnes,  Ball,  de  TMra/p.,  Ixxvii., 

Oct.  30,  p.  364. 
Extirpation  after  resection  of  upper  jaw.     Thojlas,  Gaz.  des  Mp. ,  1869, 

No.  3. 
Nouvelle  note  sur  le  diagnostic  et  le  traitement  des  polypes  fibreux  naso- 
pharyngiens.     Michaux,  Rugination,  etc. ,  Bull,  de  VAcad.  Mid.  roy. 

Belg.,  1867,  No.  6,  p.  510. 
Case  operated  on  by  a  new  method.     Cure.     Bonnes,  Bull.  Gen.  Thtr. , 

1869,  p.  364.     Consists  ta  ablation  by  means  of  a  metallic  nail  at- 
tached to  a  thimble. 
Operations  on  nasal  and  naso-pharyngeal  polyps.  Voltolini,  Berlin.  Klin. 

Troc7t.,vi.  40. 
Polype  naso-pharyngien  a  embranchements  multiples,  et  a  developpement 

rapide.     Ablation  du  maxillaire  superieur.     Arrachement  du  polype. 

Hemorrhagic  considerable,  syncope.     Introduction  du  sang  dans  les 

voies  aeriennes.     Mort  immediate.      Verneuil,  Gaz.  des  hop.,  Aug. 

9,  1870,  p.  366.     Presentation  of  specimen  and  remarks,  ibid.,  Aug. 

16,  18,  p.  379.     Continuance  of  discussion,  ibid.,  Aug.  23,  p.  387. 
Naso-pharyngeal  polyp  connected  with  membranes  of  brain.     Operation. 

Autopsy.     Remarks  at  Clin.  Soc. ,  London.     FoRSTER,  Med.  Times  & 

Gaz.,  May  27,  1871,  p.  617. 
Removed  by  turning  down  the  nose.    Tracheotomy.    Recovery.     Cabot, 

Boston  Med.  &  Surg.  Jour.,  1871,  p.  95. 


REFEEEiSrCES.  561 

Nervous  affections  of  larynx,  etc.  Hoarseness.  Loss  of  voice,  and  stridu- 
lous  breathing.     Mackenzie,  2d  ed.,  London,  1868. 

Der  hysterisclie  Krampfhusten.     Theodor,  G-reifswald,  1868. 

Nitric  Acid.— On  the  treatment  of  chronic  cases  of  sore-throat  by  the  local 
application  of  strong-  nitric  acid.  Mackintosh,  Med.  Times  &  Gaz. , 
1869,  p.  188. 

(Edema. —Traite  pratique  de  I'angine  laryngee  oedemateuse,  Paris,  1837. 

— —  La  bronchotomie  dans  le  cas  d'angine  laryngee  oedemateuse.  Sestier, 
Arch.  Gen.,  1850. 

Traite  de  I'angine  laryngee  oedemateuse.     F.  Sestier,  Paris,  1852. 

CEdema  glottidis  resulting  from  typhus  fever.     Emmet,  Phila. ,  1856. 

PiTHA,  Brit.  &  For.  Med.  CJdr.  Rev.,  Oct.,  1857. 

Ferreol,  Bull,  de  la  So.  Anat.,  1857-8. 

Deux  cas  d'oedeme  de  la  glotte  gueris  par  le  traitement  medical  seul. 

Alling,  Union  Med.,  1869,  No.  97. 

From  use  of  pot.  iod.     Nelaton,  AbeilleMed.,  x.  317. 

From  use  of  pot.  iod.  ;  fatal.     Laurie,  Stille's  TJierapeutics,  II.  p.  763. 

Sequel  of  typhoid  fever.     Trousseau,  Clin.  Med.,  Vol.  II.  ;  10  cases,  all 

fatal,  tracheotomy  in  5. 

In  croup  without  known  cause.     Death  before  operation  could  be  made, 

G'as.  AeM,1869,  p.  25. 

In  whooping-cough.     Barthez,  Gaz.  des  hop.,  1869,  32. 

Med.  Record,  Vol.  III.,  p.  449. 

Subglottic  oedema  and  permanent  stricture  of  larynx  following  typhus. 

RussEL,  Glasgow  Med.  Jour.,  Feb.,  1871,  p.  209. 

Oz^NA. —Chloride  of  lime  in.     HoRNER,  Am.  Jour.  Med.  Set.,  vol.  vi.,  p.  265. 

Chloride  of  lime  in.     AwL,  Am.  Jour.  Med.  Sci.,  vol.  xi.,  p.  543. 

Glycerine  in.     Mayer,  Am.  Jour.  Med.  Sci,  April,  1858.  p.  338. 

Iodine  and  glycerine  in.  Am.  Jour.  Med.  Sci.,  AprU,  1859,  p.  578. 

Treatment  of.     Heath  {Lancet,  1867),  Gaz.  Mtd.  Paris,  1868,  p.  362. 

Treatment  of.     Cousin,  Bull,  de  Therap. ,  1869,  p.  494. 

— ■ —  Ulcerative  syphilitic.     Lanceraux  on  Syphilis,  vol.  ii. ,  jd.  102. 

Traitement  del'ozene.  La  France  Med.,  1869,  No.  4.  p.  30. 

CEsoPHAGUs,  etc. — Bones.,  etc.,  arrested  in  alimentary  canal,  and  making 
their  way  elsewhere.  Bell  {London  Med.  Gaz.,  vol.  i. ,  No.  7),  Am. 
Jour.  Med.  Sci.,  vol.  ii.,  p.  472. 

For.  body  in  oesophagus.    Case  in  which  the  heart  of  a  fowl  was  arrested 

in  the  O. ,  remained  there  fifteen  days,  and  then  proved  fatal.     Au- 
topsy.   Denton,  Am.  Jour.  Med.  Sci. ,  vol.  v. ,  p.  544. 

Dysphagia  from  scrofulous  degeneration  of  oesophagus,  cured.  Ben- 
nett, Am.  Jour.  Med.  Sci.,  July,  1841,  p.  243. 

Inability  to  swallow,  in  an  infant.    Pierce,  Am.  Jour.  Med.  Sci.,  July 

1853,  p.  273. 

-- —  Beobachtung  einer  Hypertrophic  des  CEsophagus.  Spengler  (  Wiener 
Woch.,  No.  25),  Ganstatfs  Jahresbericht,  1853,3,  p.  278. 

Pin  swallowed,  discharged  per  rectum  ;  2  cases,  Am.  Jour.   Med.   Sci. 

Jan.,  1855,  p.  58. 
36 


562  EEFEEENCES. 

Q5S0PHAGXJS,  ETC. — Fourpence  swallowed,  removed  from  rectum,  Am.  Jour. 

Med.  Sci.,  Jan.,  1855,  p.  248. 
Cancerous    disease   of   pharynx   and    O.  ;    laryngeal  symptoms ;   larynx 

healthy.  Ware,  Am.  Jour.  Med.  Sci. ,  April,  1855,  p.  354. 
Congenital  fissure  of  (?).      Duncan,  Am.  Jour.  Med.  8ci.,  April,  1856,  p. 

517. 
The  ready  method  in  cases  of  choking.     Hall,  A^n.  Jour.  Med.  Sci. ,  April, 

1857,  p.  500. 
Spasmodic  closure  of,  terminating  fatally.     McKibbin  {Trans.  Med.  So. 

Pa.,  1858),  Am.  Jour.  Med.  Sci.,  Oct.,  1859,  p.  483. 
Hemorrhage  from  pharynx,  from  partial  swallowiug  of  a  piece  of  carti- 
lage.    Packard,  Am.  Jour.  Med.  Sci.,  AprU,  1859,  p.  377. 
Malignant  ulceration  of,  perforating  trachea.    Crowther,  Med.  Press  and 

Circ,  1866. 

Congenital  occlusion.     Parsons,  T7ie  Med.  Pecord,  1866,  p.  294. 

Sojourn  of  a  plate  (for  art.  teeth)  m  pharynx,  5  mos.     G-eoghegan,  Med. 

Press  and  Circ,  1866. 
Removal  of  penny  from   infant's  pharynx  by  laryngoscope.     JOHNSON, 

Brit.  Med.  Journ.,  1867. 
A  fork  swallowed  and  extracted  from  an  abscess  of  the  abdominal  wall. 

Arch.  Italiana  'per  la  Maladie  Nervose,  June  14,  1867.     Oaz.  liebd., 

1867,  p.  667. 

A  somewhat  similar  case  i:eported  in  Qaz.  liehd.,  1866,  p.  797. 

Acute   delirium  from  ascaries  lumbricoides  in  oesophagus.      Laurent. 

Ann.  Med.  PsycJi.,  Sept.,  1867. 
Spasm  of,  cured  by  strychnine.  Mathieu  {Abeille  Med. ,  ix. ,  286),  Stille' s 

Therapeutics,  ii.,  p.  159. 
Spasm  of,  treated  by  painting  pharynx  with  tr.  iod.     Ancelon  {Bui.  de 

the,r.,r^.,  92),  Stille's  Therap.,  ii.,  p.  781. 
Compression  of  oesophagus  by  mediastinal  carcinoma.     Death  ia  conse- 
quence.    Helber,  Memorabilien,  Dec.  12,  1868,  p.  192. 
Rupture  of  an  aortic  aneurism  into.     LooMis,  Medical  Record,  vol.  iii. ,  p. 

235. 

For.  bod.  and  mode  of  extraction.     Sayre.     Med.  Bee,  vol.  iii.,  p.  271. 

Tuberculosis  of  oesophagus.     Cases.    Chvostek  (Oes^er.  Ztschr.  f.  prakt. 

Heilk. ,  xiv. ,  27  and  28, 1868).    Paulicki  (  Virchow's  Arch. ,  xliv. ,  2  and 

3,  p.  373,  1868).     Sclmiidfs  Jahrb,  1869,  141,  3,  p.  293. 
Removal  of  copper  penny  in  a  child  set.  20  months.     Johnson  {Schmidfs 

Jahrb.,  1868,  138,  5,  p.  233.) 
Myonie  of.     Eberth,  muscular  fibres  9  cent,  long,  11  broad,  3 — 5  thick. 

VirchoiD's  Arch.,  April,  1868;    Oaz.  hebd.,  1868,  p.  477. 
Fusiform  dilatation  of.     VON  LusCHKA,  Virc7i.  Arch.,  April,  1868,  xlii., 

p.  473. 
Auscultation  of.     Clinical  uses  of  his  method,  etc.     HajNIBURGER,  Wien. 

Med.  Jahrb.,  1868,  xvi.,  123  ;  3Iedic.  Jahrb.,  xv.  Bd.,  ii.  H.  1868  ;  Rev. 

in  Oaz.  hebd.,  1868,  p.  793  ;  La  France  Med.,  1868,  p.  748  ;  Bub.  Qr. 

Med.  Jour.,  May,  1869,  p.  423. 


EEFEEEJSrCES.  563 

CEsoPHAGUS,  ETC. — Cancer  of,  with  external  openings;  and  involving  the 
larynx.  Heath  {Trans.  GUn.  So.,  London,  18G8),  A7n.  Jour.  Med. 
ScL,  Oct.,  1869,  p.  477. 

Perforation.     Drei  Piille  Erweichung  und  Durchbruch  der  Speiserohre  und 

des  Magens.     Hoffmann  (  VircJwio's  ArcMv.,  xliv.,  2  and  3,  1868,  p, 
352,  and  xlvi.,  1,  1869,  p.  124). 

Case  of  traumatic  stricture,  with  remarks.     Autopsy.      Mackey,  Med. 

Times  and  Gaz.,  Jan.  23,  1869,  p.  87. 

Congenital  malformation.     Annandale,  Edinb.  Med.  Jour.,  Jan.',  1869 

p.  598.     Similar  cases  reported  by  Sedillot,  Andral,  Martin,    Levy 
Meckel,  Roderer. 

Diseases  of,  in  children.    Steffen,  Jahrb.  f.  Kinderkr.,  1869,  ii. ,  2,  p.  143 

Linked  forceps  for  extraction  of  for.  bod.     Cut,  in  Gaz.  hebd.,  1869,  No, 

10,  p.  154.     Mathieu. 

Forceps  modelled  after  Cusco's.     Cut,  in  Gaz.  hehd. ,  1869,  No.  14,  p 

218. 

Extraction  of  a  fragment  of  bone,  etc.     Krishabek,  Gaz.  hebd.,  1869,  p 

180. 

A  large  artificial  tooth  plate,  with  projecting  angles  and  several  teeth  in 

place,  swallowed  during  sleep,  safely  voided  per  anum.    B7'it.  and  For. 
Med.-Chir.  Rev.,  Oct.,  1869,  p.  373. 

Ingenious  extraction  of  fish-hook  from.  JoNASSON.  A  large  gum  cathe- 
ter cut  square,  passed  through  a  sponge  and  firmly  fastened,  so  that 
f  in.  of  sponge  was  free  and  projected  \  in.  beyond  the  end  of  the 
catheter.  This  was  run  down  the  fishing-line,  etc.  {Australian  Med. 
Jour.,  July,  1869),  Practitioner,  Nov.,  1869. 

Ulceration  and  perforation  of  aorta  from  retention  of  a  coin.     JY.  Y.  Med. 

Jour.,  Dec,  1869,  p.  335. 

For.  bod.     Extraction  of  artificial  tooth.     Deaeden,  Brit.  Med.  Jour., 

Oct.  23,  1869. 

Extraction  de  quatre  fausses  dents,  etc.     Tillaux,  Bui.  Gen.  de  Ther., 

Oct.  30,  1869,  p.  376. 

Living  fish  in  0.  16  hours.     Stewart,  Lancet,  Sept.,  1869,  ii.,  13. 

Extraction  of  teaspoon  from.     ToDD,  Brit.  Med.  Jour. ,  Nov.  13,  1869. 

Stricture  from  swallowing  caustic  potash.  Gastrotomy  proposed,  not  per- 
formed. Cured  by  dUatation  with  boiigies.  Hutchinson  {London 
Eosp.  Rep.),  Brit,  and  For.  Med.-CUr.  Rev.,  July,  1869,  p.  28. 

Paralysis  of,  during  pregnancy.  Notable  improvement  from  electro-punc- 
ture. Return  in  second  pregnancy.  Service  of  Demarquay.  In 
connection  with  this  case,  Duchenne  recommended  not  to  pass  the  in- 
duced current  by  the  oesophageal  electrode,  for  fear  of  exciting  the 
pneumogastric  nerve,  the  nerve  of  arrest  to  the  heart,  and  the  excit- 
ing of  which  might  bring  on  syncope.  Bui.  Gen.  de  Therap.,  July 
30,  1869,  p.  82. 

Dilatation  of.     DUatation  anormale  de  I'cesophage  entre  les  lobes  pulmo- 

naires  depuis  la  base  du  cosur  jusqu'au  cardia.     Raymond,  Gaz.  Med. , 
Paris,  1869,  7,  p.  91. 


564  EEFEEENCES. 

(Esophagus,  etc. — Stricture  of  oesopliagus  at  cardiac  end,  in  a  patient  aged 
43.     Rawden,  Lwerpool  Med.  &  Surg.  Rep.,  18(59,  p.  117. 

Two  cases  of  stricture.     Mackenzie,  Med.   Times  and  Gaz. ,  July  16, 

1870. 

Removal  of  foreign  body,  by  hooking  a  pin  and  passing  a  probang  on  top, 

Trayer,  Med.  Times  and  Oaz..,  AprU  30,  1870,  p.  465. 

Case  of  a  nail  safely  passiug  through  the  alimentary  canal  of  a  baby. 

Blower,  Brit.  Med.  Jour.,  1870,  p.  204. 

Artificial    plate  removed  from   stomach  with   oesophageal  coia-catcher. 

Little,  Am.  Jour.  Med.  /Sa.,  April,  1870,  p.  558. 

Caries  of  spine  from  swaUowtag  a  naU.     Direct  communication  between 

oesophagus  and  spiue  ;  secondary  consolidation  of  lung ;  amyloid  dis- 
ease of  liver  and  spleen.  Reported  by  Dr.  Steven,  Brit.  Med.  Jour.., 
Dec.  10,  1870,  p.  629. 

Perforation  of,  by  a  bougie.      Fatal,  apparently  from  acute  pneumonia. 

Found  to  have  penetrated  some  distance  into  left  lung.  No  trace  of 
stricture  at  post-mortem.  Green.  Brit.  Med.  Jour. ,  Dec.  17,  1870, 
p.  650. 

Stomach    tube    passed   through  larynx ;    fluid    pumped  into   trachea. 

Green.     Ibid. 

■ Tuberculous  stricture  of  0.     Kratjs  {GentU.f.  Med.   Wiss..,  1869,   No. 

50);  Am.  Jour.  Med.  'SoL,  April,  1870,  p.  587. 

True  diaphragmatic  hernia,  with  stricture  of  O.    Hill,  Trans.  Path.  So. 

London.,  xxi.  1870,  p.  154. 

Post-mortem  solution  of  0. ,  and  not  of  stomach.     MoxoN,  Trans.  Path. 

So.  London.,  xxi.,  1870,  p.  159. 

Stricture  from  swallowing  lye.  Ashhurst,  Am.  Jour.   Med.  Sci.,  April, 

1871,  p.  393. 

Tumors  of  oesophagus  ;  malignant,  in  a  female  set.  48,  ill  12  mos.  ;  lungs  an  d 

glottis  slightly  affected.  Do.  iu  a  man  set.  51  ;  complained  first  of  dys- 
phagia, latterly  of  dyspnoea.  Left  vocal  cord  paralyzed.  Disease  opened 
left  carotid.  Opening  existed  between  trachea  and  oesophagus,  Med. 
Times  &  Gaz..,  1871,  p.  647. 

Perforation  of  cesophagu.s  and  vena  cava  descendens  by  a  foreig-n  body. 

CossHER  {BerUn.  Klin.  Woch.,  Oct.  24, 1870),  JST.  Y.  Med.  Jour.,  Sept., 
1871,  p.  314, 

Case  of  rupture  of  oesophagus.     Charles,  DuU.  Jour.  L.  (100),  p.  311, 

Nov.,  1870,  refers  to  many  cases,  mostly  in  inebriates.  Quotes  Gross's 
Path.  Anat. 

Ueber  cesophagus-Krankheiten,   Ektasien,   Rupturen  u.   Perforationen, 

Paralysen,  Ulcerationen,  Diver tikelbildung,  excentrische  Hypertro- 
phie.  ( Wien.  Med.  Jalirb. ,  xx.,  Wien.  ZeitscJir.,  xxvi.  5  and  6,  p.  154), 
Schmidfs  Jalirb.  Bibl.,  April,  1871. 

For.  bod.   in  oesophagus.     Dr.   Braidwood,  Liverpool  Med.   and  Surg. 

Bep.,  1869,  p.  112,  presented  at  session  1868-9,  of  Liveri^ool  Med. 
Institution  ;  pathological  specimens  of:  1.)  triangiilar  piece  of  porce- 
lain swallowed  in  bread  and  milk,  causing  a  small  lacerated  wound  in 


EEFEREISTCES.  565 

post,  wall,  penetrating  into  post,  mediastinum,  where  an  abscess  had 
formed.  2).  A  handkerchief  almost  entirely  impacted,  swallowed 
during- typhoid  fever.  3).  A  fish-hook,  swallowed;  removed  by  forceps 
tmder   chloroform. 

(Esophagus,  etc. — For.  bod.  and  death  from  abscess.  Vajst  de  Wakker, 
m  Y.  Med.  Jour.,  April,  1871,  p.  453. 

Klinik  der  CEsophagus  Krankheiten,  mit  diagnost. ,  Verwerthung  d.  Aus- 

kultation  dieses  Organs.     Hamburger  W.    Erlangen,  1871. 

(ESOPHAGOTOMY,  ETC.,  Gastrotomy  for  removal  of  a  fork  passed  in  the  throat 
to  excite  vomiting.  Caykoche  {Bei\  Med.  March.,  1829),  Am.  Jour. 
Med.  Sd. ,  vol.  vi. ,  p.  245. 

G-astrotomy  for  removal  of  a  bar  of  lead  swallowed  in  a  juggler's  feat. 

Bell.  Am.  Jour.  Med.  Sci.,  July,  1855,  p.  272;  loica  Med.  Jour.., 
April  and  May,  1855. 

For  removal  of  tooth  impacted  in  pharynx.     Successful.     Cock,  Gtiy\i 

Hosp.  Rep..,  vol.  iv. .1858. 

For  stricture,  Oaz.  hebd.,  1867,  p.  61. 

Two  cases,  with  a  history  of  the  operation.     Cheever,  Boston.    2d  ed. 

with  another  case,  1868. 

For  stricture  from  epithelial  growths.     Death.     Autopsy.    Willett,  St. 

Bartholomein  Hosp.  Bep.,  vol.  iv.,  1868,  p.  204. 

For  malignant  stricture.  Patient  survived  eighteen  days.  Author  recom- 
mends opening  gullet  at  a  point  on  a  level  with  the  cricoid  cartilage. 
Willett,  St.  Bartholomew'' s  Hosp.  Bep.,  1868,  art.  xii.,  At7i.  Jour. 
Med.  Sci.,  Jan.,  1869,  p.  195. 

For  epithelioma  of  oesophagus.     Durham,  Ouy^s  Hosp.  Bejj.,  xiv. ,  3d  S. 

ibid.,  1869,  p.  195. 

Cases  of  oesophagotomy.     Menzel,  Wien.  Med.   Woch.,  1870,  xx.  56. 

Sedillot,  Rev.  in  Edinb.  Med.  Jour.,  Feb.,  1869,  p.  727. 

Fenger,  Cooper,  Foster,  Jokes. 

Two  cases  of  internal  oesophagotomy  in  stricture  following  deglutition  of 

sulijhuric  acid.  Dolbeau  ;  one  case  of  Trelat,  from  fibrous  stric- 
ture, reported  in  Gaz.  des  hop.,  April  5,  1870,  p.  158.  Trelat's  instru- 
ment is  figured  in  Oaz.  des  hop.,  March  10,  1870,  p.  115. 

De  I'oesophagotomie  exteme.     Terrier,  Paris,  1870. 

Three  cases  of  oesophagotomy.     Cheever,   Boston    City  Hosp.   Bepi. , 

1870. 

For  strictm-e  of  oesophagus.     Maury,  Am.  Jour.  Med.  Sci.,  AprU,  1870, 

p.  365. 

With  case.     Lowe,  Lancet,  July  22,  1871,  p.  119. 

Palate. ^ — Congenital  deficiency  of,  and  modes  of  relief.  Pollock,  Am. 
Jour.  Med.  Sci.,  April,  1856,  p.  514. 

Case  of  adherence  to  pharyngeal  wall,  Gaz.  hebd.,  1867,  p.  222. 

■ G-rowth  of,  to  pharyngeal  wall.     Cure  by  dilatation.    Memorabilien,  Nov. 

16,  1868,  p.  180. 

Paralysis  of,  from  pot.  brom.  in  30  grain  doses  three  times  a  day,  for 

six  weeks.     Susband,  Edinb.  Med.  Jour.,  Jan.,  1869,  p.  656. 


566  KEFEEENCES. 

Palate.  — Fissure  of.    Beitrage  zur  Operationen  des  hervorragenden  Zwischen- 

kiefers  bei  doppelter  Lippen-  und  G-aumenspalte,   Deutsche  Klinik, 

1869  ;  No.  2,  p.  21  ;  No.  3,  p.  30. 

Abnormal  soft  palate.     Cavests,  Edinb.  Med.  Jour..,  June,  1869,  p.  1135. 

Position  of  palate  in  hanging.     Die  Stellung  des  weicben  Gaumens  beim 

Tode  durch  ErhJingen.     Ecker,  Virc7i.  Arch..,  1870,'49,  2  ;  Allg.  Med. 
Cent-Zeitg.,  1870,  No.  10,  p.  116. 
Congenital  tumor  or  excrescence  apparently  springing  from  the  base  of 

tbe  skull,  passing  through  a  cleft  in  the  palate,  and  protruding  from 

the  mouth  of  a  seven-months  foetus  stiU-bom.     Hill,  Trans.  Path. 

So.  London.,  xxi.,  1870,  p.  344. 
Idiopathic  (?)  perforating  ulcer  of  the  soft  palate  in  a  child,  healing  up 

without  operative  interference.     Hill,   Med.   Times  &  Oaz.^  1871 ; 

June  3,  p.  631. 
Fibroid  tumor  of  hard  palate,  which  had  projected  into  the  mouth,  and 

impeded   the  motion  of  the  jaws.     Tumor   had    existed   six    years 

in  a  female  aged  40.     It  was  supposed  to  be  an  exostosis,  but  came 

away  easily  with  the  gouge.     There  were  no  myeloid  bodies  in  the 

tumor.     Adams,  ibid. 
Paralysis  — Lahmung  der  Glottis,  des  Schlunds  und  der  obem  und  untem 

Extremitaten ;    zweimalige   Ausfiihrung  der  Tracheo-resp.  Laryngot- 

omie.   Wurttmb.  Coi^resp.  Bl..,  1867,  xxxvii.  10,  11. 
Glosso-Jabio-laryngeal.     Heraed,  Gaz.  hebd.^  1868,  p.  183.     Union  Med.., 

1868,  No.  35. 
Glosso-pliaryngo  and  labial.     MiGNARD,  Marchal,   l'n&.  Jfed,  1868,  p. 

314,  Gaz.  Med.  Strasbourg,  1868,  p.  9. 

Glosso-pharyngeal.     A  case  cured.     Latour,  Trib.  Med.,  1868,  p.  340. 

Glosso-pharyngeal.     Schutzenberger,  Gaz.  Med.  Paris,  1867,  p.  726. 

Labio-glosso-laryngeal.     Wilks,  Guy's  Hasp.  Pep.,  1870,  p.  1. 

Labio-glosso-laryngeal.     FouRSfiER,  Union  Med.,  1867,  51,  53. 

Labio-glosso-laryngee.      Proust,  Gaz.  des  Jiop.,  1870,  Nos.  51  and   52; 

calls  it  "  alalie." 
Recherches  icono-photographiques  sur  la  morphologie  et  sur  la  structure 

intime  du  bulbe  humain,  leur  application  a  1' etude  anatomo-patholo- 

gique  de    la   paralysie-glosso-labio-laijngee.      DrCHE>>'JsE    (of  Bou- 
logne), Arch.    Gin.,  May,  1870,  p.  539  et  seq. 
Labio-glosso-laryngeal.   Case  by  Lawson  Tait,  Med.  Times  &  Gaz.,  1870, 

p.  667.     Refers  to  Lockhart  Clarke's  papers  for  anatomy  of  nerves 

concerned. 
Laryngeal  paralysis;    cases;   laryngotomy  in  some.     Mackenzie,  Jlfet?. 

Times  &  Gaz.,  1869,  p.  356. 
Laryngeal  paralysis  of  cords,  with  abscess  ;  tracheotomy;  cure.  Marcet, 

Lancet,  ii.,  24,  Dec,  1868. 
Of  several  cranial  nerves,  including  those  of  larj-nx,  etc.     Jackson  and 

Mackenzie,  Med.  Times  &  Gaz.,  Jan.  8,  1870,  p.  35. 
Progressive    labio-glosso-laryngeal  palsy.      Clymer,   The  Med.  Pecord, 

vol.  v.,  p.  339. 


EEFEEEJSTCES.  567 

Phakynx. — Extirpation  of  pharyngeal  tumor.  DuGAS,  Am.  Jour.  Med.  Sei.^ 

July,  1853,  p.  280. 
Inhalation  of  CO5  in  granular  pharyngitis,   Am.  Jour.  Med.  Sci.,  April, 

1859,  p.  543. 
Extraction  from  pharynx  of  a  needle  which   had  penetrated  the   neck. 

Murray,  Med.  Times  <&  Gaz. ,  May  7,  1859. 
Pharyngitis  and  stomatitis  leucemique  {Vircli.  ArcJi.,  Feb.  25,  1868),  Gaz. 

hebd. ,  1868,  270. 
Pharyngeal  polyp  at  nine  years.     Marsh,  Med.   Times  &  Gaz..,  Nov.  13, 

1869,  p.  585. 
Pharyngeal  erysipelas,  making  its  way  on  the  face  through  the  lachry- 
mal canal.     Gallard  {Gaz.  des  Mp..,  1868,  47),  Schmidt's  Jahrb., 

Jan.,  1869,  p.  35. 
Pharyngeal   erysipelas  extending   into  nasal  cavities,  conjunctiva,   face. 

RiGAL,  Gaz.  des  hop.,  20^1869. 
Pharyngitis.     Marmisse.     Consecutive  oedema  of  glottis  ;  tracheotomy ; 

double   broncho-pleuro-pn.eumonia ;    recovery  with   partial    aphonia. 

Journal  de  Bard.,  4  Sec.  I. ,  p.  399,  Sept. ,  1870. 
— ■ —  Syphilitic  affections  of.    Bemerkungen  zur  Pathologic  und  Therapie  der 

Pharyngealerkrankungen  Syphilitischer.     KoHN  (  Wien.  Med.  Presse, 

ix.  44,  46,  1868),  Schmidt's  JaJirb.,  1869,  141,  3,  p.  299. 
Adenoid  vegetations  in  the  pharyngo-nasal  region.  Ueber  adenoide  Vegeta- 

tionen  in  der  Rachennasenhohle.     Meyer,  zu  Kopenhagen  {Hospitals 

Tidende,  Nov.  4,  ii.,  1865) ;  extensively  reviewed  in  Schmidfs  Jahrb., 

1869,  141,  p.  325.  Communicated  in  English  to  Medico- ChiruTgical 
Transactions,  London,  vol.  liii. ,  1870,  p.  191.     Illustrated. 

Case  of  stricture.    Hayden  {Path.  So.  Dublin),  Dublin  Jour.,  xlviii.  (96), 

p.  660,  Nov.,  1869.  A  remarkable  case,  compressing  larynx  and  fold- 
ing the  edges  of  the  epiglottis  together ;  illustrated. 

PirrsiOLOGY. — Die  Functionen  des  Schlund-  und  Kehlkopfes,  etc.  Merkel, 
Leipzig,  1862. 

On  the  function  of  the  epiglottis.     ScHiFP,  MolescJioW s  Untcrsucli. ,  1864, 

ix.  4,  p.  321. 

Observations  on  the  physiology  of  the  larynx.     Wyllie,   Edinb.  Med. 

Jour.,  Sept.,  1866. 

On  action  of  superior  larj'ngeal  nerve.     Bidder,  Gaz.  Med.  Paris,  1867, 

p.  27. 

L'acte  de  la  deglutition,  son  mecanisme.     MouRA,  Paris,  1867. 

Recherches  experimentales  sur  les    divers   mecanismes   d' occlusion   du 

larynx.     Krishaber,  Gciz.  Mid.  Paris,  1869,  Nov.  6,  p.  596. 

On  the  functions  of  the  trachea.     Lbven,  Gaz.  des  hop.,  1869,  No.  137. 

Allg.  Med.  Cent.-Ztg.,  1870,  No.  13,  p.  148.  Dancet,  March  5,  1870, 
Am.  Jour.  Med.  Sei.,  July,  1870. 

— ' —  A  case  illustrating  the  physiology  and  pathology  of  the  cervical  portion  of 
the  sympathetic  nerve.  Abundant  discharge  from  one  nostril  only. 
Ogle,  Med.  Ohir.  Trans.,  vol.  ii.,  1867;  Am.  Jour.  Med.  Sci.,  April, 

1870,  p.  477. 


568  EEFEEEJSrCES. 

Physiology. — Osteomes  du  nez,  et  des  sinus  de  la  face.     Osteomes  de  I'organe 

de  I'olfacteur.     Goubert,  1870,  Rev.  Arch.  Oen.,  1870,  214. 
Scalds,  of  pharynx  and  epiglottis  by  boiling  liquids.   Thiessen  ;  urg-es  tracheo- 
tomy, Oaz.  hebd.,  1868,  p.  447,  6az.  Mkl  Strasb.,  1868,  p.  80. 

Of  the  larynx.     Bevan,  Dui.  Qimr.  Jour.  Med.  Sd.,  Nov.,  1866. 

Of  pharynx,  etc.,  by  hot  liquids.    Clark's  Lectures  an  Surgical  Biagno- 

sis.,  <&G.,  London,'  1870,  p.  229. 
Small-Pox.  — Kehlkopf  AfEectionen  mit  todtl.  Ausgange  bei  anomaler  Variola. 
Berkutz,  U  Union,  1869,  p.  153. 

Smell. Diagnosis  by.     At  a  meeting  of  Chir.  So.  {Brit.  Med.  Jour.,  March 

4  1871),  the  president  alluded  to  the  diagnosis  of  syphilitic  and 
other  diseases  by  the  sense  of  smeU.  Thirty  years  ago  Dr.  Stokes,  of 
Dublin,  expressed  the  opinion  that  the  nose  might  be  able  to  detect 
the  difference  between  i^neumonia  and  bronchitis.  The  Med.  Times, 
1871,  p.  318. 
SneezikG. — Convulsive  sneezing,  and  its  relationship  with  migraine,  bronchial 
asthma,  and  hay  fever.  Ferber  {Arch,  der  Heilkunde,  18Q7),  Am. 
Jour.  Med.  Scl,  July,  1870,  p.  245. 
Sore-Throat. — A  treatise  on  malignant  angina,  or  putrid  and  ulcerative  sore- 
throat,  etc.     Johnstone,  Worcester,  1779. 

Traite  de  I'angine  laryngee  oedemateuse.     Sestier,  Paris,  ii.  1852. 

Angina  pharyngea  oedematosa  in  children.    Wertheimer  {Journal  der 

Kinderk.,  Bd.  xxxii. ,  Med.  Times  &'Gaz.,  Dec.  24),  Am..  Jour.  Med. 
5ci.,  April,  1860,  p.  537. 

Catarrhal,  simulating  onset  of  typhoid  fever,  Oaz.  held.,  1868,  p.  312. 

Traite  des  angines.     Ch.  Lasegue,  Paris,  1868. 

Die  Migrane  ist  eine  Angina,  der  akute  Magencatarrh  eine  Neurose.    Ueber 

d.  Bedeutung  d.  Angina  faucium,  ihre  Verbindung  u.  ihren  Zusammen- 
drang  mit  einer  Eeihe  von  EZrankheiten.    Ferd.  Wydler,  Aaran,  1870. 

Ulcero-membranous  angina.  Da  Costa.  Am.  Jour.  Med.  Sci. ,  July,  1870, 

p.  129. 
Angine  gangreneuse.  Guement  (Societn  Medico-Chirurgicale  de  Bor- 
deaux, 1869).  Reviewed  in  Arch.  Gen.de  Mich,  Sept.,  1870,  p.  364. 
A  case  under  Barillier  in  a  lad  13,  occurring  in  hospital  after  a  cold 
douche.  Death.  Autopsy. 
Spasm  and  Laryngismus  Stridulus. — Tendency  to  spasm  of  glottis,  pro- 
duced by  asparagus.     De  Salle,  Am.  Jour.  Med.  8d. ,  vol.  ix.  p.  216. 

Laryngismus  and  its  effects.     Marshall  Hall,  Am.  Jour.  Med  Sci., 

July,  1853,  p.  55. 

Troy,  notice  of,  in  Am,.  Jour.  Med.  Sci.,  Oct.  1855,  p.  455. 

Wardell,  Brit.  Med.  Jour.,  May,  1868. 

Valerian  in  laryngismus  stridulus.  Hill,  Brit.  Med.  Jour.,  April  11,  1868. 

Ergoten  in  laryngeal  spasm.     Brit.  Med.  Jour. ,  Sept.  5,  1868. 

Zur  Therapie  des  Asthma  infantum.     L()SCIiner,    Allg.  Med.    C.-Ztg., 

1868,  83,  p.  709. 

in  children,  its  connection  with  eclampsia.      Henoch,  Am.  Jour.  Med. 

Sci.,  July,  1868,  p.  269. 


EEFEKENCES.  509 

Spasm  and  Lakyngismus  Stridulus. — Spasm  of  glottis,  removing  tube  af- 
ter tracheotomy  for  croup.  Barthez,  Oaz.  des  hop.^  1869,  10  ;  also, 
ibid.  p.  39. 

with,  diphtheria  of  the  colon ;  combined  with  scarlatina.     Betz,  Memo- 

rabilieii.,  1869,  xiv.  8. 

Two  cases  of  laryngismus  stridulus  successfully  treated  by  bromides  in- 
ternally, and  iodine  externally.  Varick,  Trans.  Med.  So.  New  Jer- 
sey., 1868;  Am.  Jour.  Med.  Sci..,  April,  1869,  p.  495.   . 

LoscECNER  (Baier.  Intel.  Blatt.  40),  PracUtiorw\  Jan  1869,  p.  56. 

Chloride  of  bromium  in.     PoLiTZER  {Jakrb.  f.  Kind..,  iii.  h.  4),  Boston 

Med.  &  Surg.  Jour.,  Jan.  13.  1871,  p.  20. 

Clinical  lecture  on.     Johnson,  Brit.  Med.  Jour..,  May  6,  1871,  p.  469. 

Syphilis. — Laryngotomy  for  syphilitic  disease.  Amerman,  Am.  Jour.  Med. 
Sci.,  Jan.  1857,  p.  284. 

Syphilitic  affections  of  the  larynx.     Van  Buren,  iV".   T.    Med.    Times, 

July  7,  1860. 

Nouveau  traite  des  maladies  veneriennes.     Robert,  Paris,  1861. 

Syphilitic  ulcers  on  the  walls  of  the  naso-pharyngeal  space.     TiJRCK, 

AUg.  Wien.  Med.  Ztg.,  1861.    No.  48. 

Syphilitic  affections  of  the  larynx.     Briddon,  iV.  Y.  Med.  Times,  Dec. 

1862,  p.  327. 

Syphilitic  laryngitis.     Hamilton,  Bub.  Jour.,  xxiii.,  1862. 

TJeber  Krank.    einzelner   Theile   des  Kehlkopfs,    etc.      Lewin,   Vircli. 

Arch.  1862,  xxiii.  p.  587. 

Davies,  2Ied.  Times  &  Oaz.  1862,  May,  241. 

Retrecissements  syphilitiques  de  la  trachee.     BoECKEL,  Oaz.  des  7wp., 

1864,  3. 

Die  Syphilit.  Erkrankung  des  Kehlkopf es.   TiJRCK,  AUg.  Wien.  Med.  Ztg. , 

1864,  viii.  43. 

Eruptions  du  larynx  survenant  dans  la  periode  secondaire  de  la  Syphilis. 

Dance,    1864. 

On  Syphilis.     Translation.     Lanceraux,  8yd.  So.  Ed.,  1869. 

Syphilitic  stenosis  of  larynx,   tracheotomy.     Hagel,    Union  Med.    Oi- 

ronde,  1868,  p.  93. 

Syphilitic  laryngitis  ;    tracheotomy  ;  mercury  ;  cure.     Trib.  Med. ,  1868, 

p.  559. 

• Die   Syphilis  der  Schleimhaut  der  Mund — Rachen — Nasen — und  Kehl- 

kopfhohle.     KoHN,  Erlangen,  1866. 

deep  ulcer  at  base  of  arytenoid  in  a  married  woman  infected  by  child- 
bearing  No  primaries.  MORGAN,  Med.  Press  &  Oirc,  Oct.  14,  1868. 
Banking's  Abst.,  1869,  p.  139. 

Sulphurous  acid  spray  in  syphilitic  ulcers  of  larynx.     PuRDON,  Bienn. 

Betrosp.  Syd.  So.,  1867-8,  p.  45. 

• of  larynx  and  liver.  Wiiipham,  Trans.  Path.  So.  London,  xxi.  1870,  p.  218. 

Tracheotomy  in  syphilitic  affections.     Trelat,  France  Mklicale,  1868, 

p.  739  ;  1869,  p.  285.  Med.  Times  &  Oaz.,  Dec.  19,  1868.  Oaz.  liebd., 
1869,  Nos,  13,  17,  18,  19,  20.     Oaz.  Med.,  Paris,  1869,  p.  172. 


570  REFEKEIs-CES. 

Thkoat. — On  diseases  of  the  mucous  membranes  of  the  throat.  Wagstaff. 
London,  1851. 

A  treatise  on  diseases  of  the  air-passages,  etc.  Green,  4th  edit.  N.Y.,  1858. 

A  peculiar  sore-throat.   Whitney,  J.m.  Jour.  Med.  Sci.,  Oct.,  1859,  p.  485. 

Sore-Throat  and  the  laryngoscope.     James,  London,  1861. 

On  Diseases  of  the  Throat.     Dixon,  London,  1865. 

On  the  Throat  and  Windpipe.     Gibb,  2d  edit.,  London,  1866. 

On  the  Throat.     Yearsley,  8th  edit.     London,  1867. 

On  some  diseases  of  the  oSTose,  Throat,  etc.     Moore,  London,  1867. 

Suicidal  and  homicidal  wounds  of.     Taylor,  Guy^s  Ilospt.   Rep. ,  1869, 

vol.  xiv. 

Morbid  Throat  and  Consumption.     Alison,  London,  1869. 

Thymus. — Observations  on  the  Surgical  Anatomy  of  the  Head  and  Neck. 
Allan  Burns,  2d  edit.,  Glasgow,  1824. 

The  anatomy  of  the  thymus  gland.     Cooper,  London,  1832. 

Observations  on  the  sudden  death  of  children  from  enlargement  of  the 

thymus  gland.     Montgomery,  Dtib.  Jour.  Med.  Sci. ,  1836,  p.  429. 

On  the  thymus  gland  ;   its  morbid  affections,  and  the  diseases  which  arise 

from  its  abnormal  enlargement.    Chas.  A.  Lee,  Am.  Jour.  Med.  Sci. , 
Jan.  1842,  p.  135. 

A  Physiological  Essay  on  the  Thymus  Gland.     John  Simon,  London, 

1845. 
Thyroid. — Aneurism  of,  cured  by  ligature  of  the  two  thyroid  arteries  {Lond. 

Med.  &  PTiys.  Jour..,  Feb.  1838),  Am.  Jour.  Med.  Sci,  xxi.  p.  535. 
gland     De  Thypertrophie  de  la  glande  thyroide  des  femmes  enceintes. 

GuiLLOT,  Arch.  Oen.,  Nov.  186G,  p.  513. 
Functions  of.      Qaz.  held. ,  1867,  p.  640. 

Tumor  of  neck  in  connection  with  thyroid  gland.     Removal.     Recovery. 

Structure  of  tumor  thyroidal.     Illustrated.      Poland,  Guy\s  Hospl. 
Rep.  1871,  p.  484. 
Tonsil. — Extensive  oedema  supervening  after  removal.     Williams,  Arn.  Jour. 
Med.  Sci.,  July,  1853,  p.  225. 

On  the  treatment  of  enlarged  tonsils  at  any  period  of  life.     W.  J.  Smith, 

London,  1865. 

Diseased  tonsUs  and  their  removal  without  cutting.     Mackenzie,  Lon- 

don, 1868 

BROCA'snew  tonsillotome,  figured  in  Gaz.  7ieM.,  1868,  p.  540. 

On  the  removal  of  enlarged  tonsils  without  cutting,  with  123  cases.     A. 

RUPPANER,  Med.  &  Surg.  Rep.,  Phil.  1869  Nov.  20,  27. 

Concretions  in  tonsils.     Fall  von  Mandelsteinen.     ToBOLD.  Berlin.  Klin. 

Woch.,  vi.  3,  1869,  p.  31. 

Des  inconvenients  qui  resultent  de  I'hypertrophie  des  amj'gdales.     BoY- 

RON,  Sante  Publique,  1869,  No.  8,  p.  59. 

Chancre  of  tonsil  in  nurse,  from  syphilitic  infant.     Gondouin,  Union. 

43,  1869. 

Tonsillothlipsie.  Nagel,  Wien.  Med.  Woch.,  1870,  No.  7,  p.  108.  Slit- 
ting of  the  mucous  membrane  and  evulsion  by  the  finger. 


EEFEEEKCES!  571 

Tonsil. — Strangulation  of  the  tonsils.     Aulnoit  {Gaz.  lieM.  1870,  No  17), 

RanJcing's  Abst,  July,  1870.  p.  174. 
■ Abscess  in  tonsil  punctured.     Fatal   hemorrh.age.     Gjreen,   Brit.   Med. 

Jour.,  Dec.  17,  1870,  p.  651. 
Cystic  tonsil.     Parry,  The  Med.  Tmes,  June  1,1871,  p.  324. 

Hemorrhage  after  excision,  arrested  by  emesis.     Cases.     Hood  (Lancet, 

Oct.  29),  BanMru/s  AM.,  Jan.  1871,  p.  187. 

Encephaloid  tumor  of  tonsil.     Cheever,  Boston  City  Hospl.  Bep.,  1870; 

Am.  Jour.  Med.  8d.,  April,  1871,  p.  515.     Sailor,  ^t.  43.     Excision  by 

external   section.      Satisfactory   result.      Wound   closed   entirely   in 

31  days. 
Trachea. — Complete  division  of,  etc.    Cure.  Am.  Jour.  Med.  Sci.,  vii.  p.  248. 
Longitudinal  rupture  of.     Suicide  or  homicide  ?     Am.  Jovr.  Med.  Sci. , 

Jan.   1853,  p.  263. 
'  Gunshot  wound  of,  and  other  injuries.     Moses,  Am.  Jour.  Med.  Sci.,  Jan. 

1857,  p.  29. 

displacement  of,  and  its  separation  from  larjTix  by  the  kick  of  a  horse- 

Berger  (Lancet,  9,  6,  56),  Ani.  Jour.  Med.  Sci.,  Jan.  1857,  p  254. 

Rupture  of,  from  a  fall.     Atlee,  Am.  Jour.  Med.  Sci.,  Jan.   1858,  p. 

120. 

Aneurism  of  aorta  pressing  upon  trachea  and  causing  violent  symptoms 

of  asthma.     Darrach,  Ain.  Jovr.  Med.  Sci.,  Jan  1860,  p.  82. 

r  Rupture  of  trachea  during  parturition  (3  cases  reported  by  Meniere, 
ArcJi.  de  Med.,  1829;  2  by  Depaul,  Gas.  Med.,  1842;  Ci-oqf'et,  Be 
r influence  des  efforts  sur  les  organes  renfermes  dans  la  cavite  thoracique, 
1820;  SoYRE,  G^rts.  (?fs /io^:).,  1864,  p.  367).  li-EMAUCiJJAY,  Pneumatol- 
ogie  Medicale,  Paris,  1866,  p.  175 

Malformation  of.     Raymond,  Gaz.  Mkl.,  Paris,  1867,  p.  300. 

Cases  of  injury  to.     Long,  Liverpool  Med.  &  Surg.  Bep.  vol.  1, 1867,  p.  P. 

Rupture  of  trachea.     Med.    Times  <&  Gaz.,  vol.   13  ;  Holmes'  System  of 

Surgery,  vol.  2,  p.  286.     lied.  C7iir.  Bev.,  No.  75,- p.  275. 

Horizontal  Durchtrennung  der  Luf  trohre  in  2  Knorpelringe  bis  zur  hintern 

Knorpellosen  Wand.  Heilung.  Rosenbaum,  Wien.  Med.  Woch., 
xvii.  36. 

Windpipe  and  consumption.     Garrett,  Loudon,  1868. 

protection  to  trachea  frora  hemorrhage  during  operations.    Apparat,  wel- 

cher  die  Anasthesirung  bei  Oberkief erresectionen  ermoglicht.  Below, 
AUg.  Med.  Cent.  Zeitg.  No.  13,  1870,  p.  145.     3  illustrations. 

displacement   from  external  pressui-e.      M.^ckenzie  (Trans.  CMr.   So. 

London)^  Am.  Jour.  Med.  Sci.,  April,  1870,  p.  487. 

Cancer  of  trachea  and  oesophagus  with  swelling  of  arytenoid  cartilages. 

Autopsy.  Interior  of  larynx  healthy,  cancerous  mass  at  third  ring  of 
trachea  posteriorly,  perforating  oesophagus,  embedding  right  common 
carotid  and  internal  jugular,  right  vagus,  and  involving  right  pleura. 
Wood,  Brit.  Med.  Jour.,  1871,  p.  196. 

Stricture  from  syphilitic  ulceration.     Erichsen,   Med.    Times  <&  Gaz., 

1871,  p.  394. 


572  EEFERElSrCES. 

Trachea.^ — Syphilitic  constriction  of  Trachea.     Specimen  exhibited  to  Path. 

So.  Feb.  21,  1871.     Mackenzie— deposits  in  liver.     Med.   Times  & 

Gaz.,  March  11,  1871,  p  293. 
Tumors. — Surgical  obsei-rations  on  tumors.     Warren,  Boston,  1837. 

Lectures  on  tumors.     Paget,  London,  1853. 

Super-lai'jTigeal  encysted  tumors  ;  or  encysted  bursal  tumors  in  front  of 

thelar;yTix.   10  cases.    Hamilton,  iV".  T.  Med.  Jour.^S&u.  1870,  p.  50. 

Primitive  cancer  of  Larynx,  Fauvel  ;    tracheotomy  by  Demakquat. 

Death  from  pneumonia  at  fourth  day.  Two  other  cases  only  said  to 
be  on  record,  and  these  reported  by  Louis  and  Trousseau.  Oaz.  des 
Jiojj..  March  19,  1870,  No.  33.  Another  case  is  reported  by  Navratil 
in  Viemia  Medical  Presse,  1868,  24  and  25.  —See  also  Paget  on  tumors, 
edit.  1853,  p.  428. 

Encephaloid  Tumor  of  rapid  growth,  above  right  clavicle,  inducing  cough, 

dyspnoea,  and  dysphagia.     Bartlett,  Am.  Jour.  Med.  Sci. ,  AprU, 
1871,  p.  592. 
Uvula. — Microscopic  appearances  of  a  relaxed  uvula.     Inman,  Med.  Times  & 
Oaz..,  1852,  July  31. 

Amputation  of,  by  double  flap  method.     Maunder,  Lancet.,  Aug.  22, 

1868. 
Whooping-Cotjgh.  — Cured  in  eight  days  by  endermic  use  of  mor^jhia.     Meter 
{Arch.  Gen.).,  Am.  Jour.  Med.  Sci.,  vol.  v.  p.  501. 

Immediately  arrested  by  use  of  belladonna  and  hydrocyanic  acid  as  used 

by  Dr.  Kahleiss.     Valk,  Am.  Jour.  Med.  Sci. ,  vol.  vii.  p.  417. 

Prussic  acid  in.     Atlee,  A^n.  Jour.  Med.  Sci.,  x.  p.  128. 

De  Pemploi  des  cauterizations.     JouBERT,  Union  Med.,  1851,  No.  146. 

Topical  treatment.     Eben  WATSON,  Am.  Jour.  Med.  Sci.,  Oct.  1851,  p. 

490. 
Chloroform  in.     Churchill,  Am.  Jour.  Med.  Sci.,  Oct.  1853,  p.  497. 

Combined  local  and  constitutional  treatment.     Pearce,  Am.  Jour.  Med. 

Sci.,  Oct.  1857,  p.  519. 

Krankheiten  der  Bronchien-  und  der  Lungen-Parenchyms.     BlERMER,  in 

Virchow's  Handbuch  der  Speciellen  Pathologic  und  Therapie.  Erlan- 
gen,  1865. 

Brotvn-Sequaed  on.     The  Mediccd  Record,  vol.  i.  p.  227. 

Influence  of  expired  air  during.      Gnz.  hebd.  1867,  p.  525  ;  Pouchet, 

Gaz.  Med.  Paris,  1867,  p.  518. 

Vapors  of  tar,  resineone,  gas,  benzLue,  etc.    Results  of.     Gaz.  Med.  Stras- 

iourg,  1867,  p.  230. 

Inhalations  in.     Steepen  {Jour.f.  IBnd.,  1806,  1  &  2),  Gaz.  Med.  Stras- 

bourg, 1867,  p.  235. 

Compressed  air  in  (Journ.  f.  Einderk.,  1867,  Nos.  11  &  12),  Gaz.  Med. 

Strasbourg,  1868,  p.  118.  Sandahl  of  Stockholm,  La  Trib.  Med., 
1868,  p.  558. 

Bromide  of  potassium  in.     De  Beaufort,  Am.  Jour.  Med.  Sci.,  April, 

1868,  p.  536. 

Animalcules  of.     Med  News  &  Lib.,  1868,  p.  27. 


EEFEEENCES.  573 

Whooping-Cough. — Ergotine  in.     Brit.  Med.  Jour.,  Sept.  5,  1868. 

Valerian  in.     Hill,  Brit.  Med.  Jour..,  April  11,  1868. 

Oppolzer  on.     Memorabilien,  xiii.,  No.  7,  p.  176. 

Melon    Syrup,  containing  codeia,  used  as  a  specific  in  Italy.     Journal 

fm-  Kinderkr.,  1868,  7  &  8. 

Carbolate  of  lime  in.     Snow,  Medical  Record.,  1869,  Jan.  15. 

hydrochlorate  of  quinine  in.     BiNZ,  Practitioner,  1869,  Nov.  p.  304. 

CEdema  of  glottis  in.     Tracheotomy.     Death.     Bakthez,  Qaz.  deshop.., 

33,  1869. 

Sulphuret  of  potash  in.     Mackelcak,  N.  Y.  Med.  J. ,  Jan.  1869,  p.  444. 

Discovery  of  the  fungus  of.     Letzterich,  VircJi.  Arch..,  March,  1870. 

loduret  of  silver  in.     Bartlett,  Am.  Pract.,  Feb.  1870. 

Vapor  of  ammonia  in.     Grantham,  Brit.  Med.  Jour.,  1871,  p.  323, 

Ulceration  of  frgenum  linguse  in.      Maccall  {Glasgow  Med.  Jour.,  Feb- 

1871),  Am.  Jour.  Med.  Soi.,  April,  1871,  p.  564. 
Wounds. — Occlusion  from  wound  in  suicidal  attempt;   re -establishment  of 
canal  in  larynx  ;  tracheotomy,  etc.     LiSTON  {Edinb.  Med.  Jour. ,  Jan. 
1828),  Am.  Jour.  Med.  Sci.,  vol.  ii.  p.  214. 

Danger  of  penetrating  wounds  of  trachea  and  larynx.     Am.  Jour.  Med. 

Bci.,  April,  1855,  p.  436. 

"Wound  of  larynx  and  other  part's ;  ligation  of  carotid.     CoLE,  Am.  Jour. 

Med.  Sci.,  June,  1858,  p.  213. 

Verletzungen   und   Chirurgische   Krankheiten   der   Halsgegend.     LouiS 

Stromeyer,  Freiburg,  1865. 

Plaie  du  larynx,  re-unie  par  suture,  et  gueri  sans  accidents.     Melanges 

de  cliniques  par  A.  Lejeal,  Paris,  1868.     Arc7i.  Gen.,  Jan.  1869. 

Plaies  du  larynx,  de  la  trachee  et  de  i'oesophage.     Horteloup,  Paris, 

1869. 

Cicatricial  atresia  from  suicidal  wounds.     Narbige  Atresie  des  Larynx 

durch  Selbstmordversuch  (1864).  Kughler,  Deutsche  Klinik,  1869, 
p.  169. 

Plaie  transversale  du  larynx  par  instrument  tranchant ;  suture  ;  guerison 

par  premiere  intention.  Prestat,  Bui.  Oen.  de  Ther.,  Sept.  15-30, 
1869,  p.  237.      Gas.  des  hop.,  1869,  101,  p.  399  ;  103,  p.  405. 

Wound  and  partial  division  of  cricoid  cartilage.     Death  on  fourth  day 

from  pleurisy,  from  contiguity  of  pleura  to  burrowing  abscess  in  are- 
olar tissu.e  behind  trachea. — Five  cases  of  wound  through  thyro-hyoid 
membrane.  All  recovered.  One  extended  upwards  and  involved  the 
epiglottis.  Le  G-ros  Clarke's  Lectures  on  Surgery,  London,  1870, 
pp.  225,  237.  See  notice  of  other  cases,  of  suicide  and  attempted 
suicide,  in  same  lecture. 

Division  of  larynx  and  oesophagus   (in  an  attempt  at  suicide)  without 

wounding  the  jugulars  or  carotids.  Alston,  Richmond  and  Louisville 
Med.  Jour.,  Dec.  1871. 


INDEX. 


Ablutions  in  ozrena,  s!G7.  i 

Aborting  coryza,  methods  of.  255. 
Abscess,  nasal,  250. 

from  wounds  of  the  pharj-nx,  209. 
of  the  frontal  sinuses,  326. 
of  the  neck,  507. 

cesophagus,  154. 
pharynx,  148. 

in    phlegmonous    sore 
throat,  82. 
Acid  nitrate  of  mercury  in  the  treatment  of 

laryngeal  gro\rths,  424. 
Accidental  choking  as  a  cure  of  aphonia,  474. 

woimds  of  the  pharynx,  210. 
Accretions,  calcareous,  in  the  nasal  fossse,  305. 
Acute  laryngitis,  333. 
Acuteness  of  smell,  291. 
Adenomas  of  the  nostrils,  315. 
of  tnie  palate,  137. 
Adhesions  in  enlarged  tonsils,  132. 

of  the  palate,  140. 
Ammonia,  in  whooping-cough,  485. 

inhalations  of  miariate  of,  in  coryza, 

257. 
nascent  fumes  of  muriate  of,  276. 
Amputation  of  the  uvula,  145. 
Amygdalitis,  82. 

Analogy  between  diphtheria  and  scarlatina,  108. 
Anatomy,  regional,  of  the  larynx,  47. 
Anesthesia  in  laryngoscopy,  28. 

in  the  operation  of  thjTotomy,  448. 
Aneurism  of  the  aorta,  a  cause  of  aphonia,  466. 
Angina,  78. 

maligna,  89. 
Anginose  scarlatina,  109. 
Anosmia,  289. 

Anterior  examination  of  the  nasal  passages,  75. 
Aorta,  aneurism  of  the,  466. 
Appearance  of  the  image  of  the  larynx  in  the 

laryngoscopic  min-or,  54. 
Aphonia,  461. 

from  aneurism  of  the  aorta,  466. 
Apparatus,  iUiTminating,  33,  84. 

Tobold's  illuminating,  31. 
to  increase  the  illumination  of  the 
phai-yngeal  cavity,  2t5. 
Aj-terj'  forceps,  torsion,  511. 
Artificial  light,  in  examinations  of  the  throat,  30. 
use  of,  m  laryngoscopy,  29. 
openings  into  the   larynx    and 
trachea,  496. 


Arj'teno-epiglottic  folds,  48. 

muscle,  56,  62. 
Arji:enoid  cartilages,  47. 

muscle.  61. 
Arytenoidal  commissure,  58. 

fissiu-e,  58. 
Asphyxia  from  abscess  of  the  pharynx,  148. 

growths  in  the  lai-ynx,  408. 
Atmosphere,  warm  and  moist,  in  croup,  400. 
Auditory  apparatus,  affections  of,  in  scarlatina, 

107. 
Aural  implications  in  syphilis,  115. 
Auscultation  of  the  oesophagus,. 217. 
Auto-infra-glottic  laryngoscopy,  45. 
Auto-laryngoscopy,  11,  35,  449. 
Barking  cough,  478. 
Bathing,  87. 
BeUocq's  canula  for  tamponing  the  posterior 

nares,  250. 
Bibliograph3^  532. 
Bifid  uvula,  147. 

Billroth,  on  excision  of  the  oesophagus,  220. 
Blood-vessels  of  the  larynx,  65. 
Blows  on  the  head,  a  cause  of  anosmia,  290. 
Bougies  for  dilating  the  oesophagus,  219. 
Bromine  inhalations  in  croup,  402. 
Bronchial  septum,  the,  457. 
Bronchocele,  515. 
Brush-holders,  386.    . 
Burns  and  scalds  of  the  throat,  123. 
Bursa,  the  pharyngeal,  179,  181,  187. 
Bin-sal  tumors  in  the  thyro-hyoid  region,  513. 
Calcareous  accretions  in  the  nasal  fossfe,  305. 

concretions  in  the  tonsils,  125. 
Camphor  by  inhalation  in  coryza,  257. 
Cancerous  tumors  of  the  tonsils,  125. 
Canule  for  plugging  the  posterior  nares,  250. 

use  after  tracheotomy,  498. 
Carbonaceous  sputa  following  the  inhalation  of 

smoke,  124. 
Carbonate  of  ammonia  in  croup,  403. 
Caries  of  the  cervical  vertebras,  149. 
Cartilages,  histology  of  the  laryngeal,  65. 

of  Wrisbei-g,  48. 
Carotid,  dysphonia  following  ligation  of  the, 

466. 
Casts,  in  membranous  sore  throat,  94. 
Catarrh,  nasal,  263. 
Catarrhal  croup,  396. 
Catechu  in  elongated  uvula,  146. 


76 


IITOEX. 


Catheterization  of  the  air-passage  in  croup,  405. 

larynx  and  trachea,  505. 

Caustic  applications  to  laryngeal  growths,  419. 

holders,  laryngeal,  419. 
Cephalo-pharyngeal  muscle,  179. 
Cerebral  disease,  anosmia  from,  290. 
Cerebral  paresis  from  influenza,  263. 
Chancres  of  the  mouth  and  throat,  11.3. 
Chloride  of  gold  iu  chronic  pharyngitis,  17.3. 
lime  in  ozajna,  274. 
•  Choking  somethnes  a  cure  in  aphonia,  474. 
Chromic  acid  in  enlarged  tonsils,  132. 

the     treatment     of    laryngeal 
growths,  426. 
Chronic  elongation  of  the  uvula,  145. 

enlargement  of  the  tonsils,  126. 
follicular  pharjTigitis,  156. 
inflammation  of  the  trachea,  391. 
larjTigitis,  347. 

following  smaU-pox,  106. 
nasal  catarrh,  263. 
Cleft-palate,  141. 

appearance  of  glandular  tissue  at 
vault  of  pharynx  in  a  case  of,  185. 
Clergyman's  sore  throat,  158. 
Coin-catcher,  cEsophageal,  236. 
Cold  as  a  cause  of  disease  of  the  throat,  4. 
in  epistaxis,  248. 
in  the  head,  251. 
sponge-bath,  87. 
Common  sore  throat,  79. 
Compression  in  treatment  of  enlarged  tonsils, 

127. 
Concretions  in  the  tonsils,  125- 
Congenital  fistule  of  the  oesophagus,  214. 

occlusion  of  the  oesophagus,  212. 

posterior  nares,  295- 
stricture  of  the  oesophagus,  216. 
tumors  of  the  larynx,  418. 
Connective  tissue  of  the  neck,  diffuse  inflamma- 
tion of  the,  507. 
Constriction  of  the  oesophagus,  221. 

trachea,  393. 
Consumption  in  relation  to  enlarged  tonsils,  127. 
simulated   by  constriction  of  the 

trachea,  394. 
symptoms  of,  produced  by  elonga- 
tion of  the  uvula,  169. 
Control,  voluntary,  over  tongue  and  throat,  8. 
Contusions  of  the  larynx  and  trachea,  495. 
Cords,  false  vocal,  49. 

vocal,  49. 
Coryza,  250. 

chronic,  263. 

from  reflex  irritation,  265. 
idiosyncratic,  258. 
syphilitic,  119. 
Cough,  ear,  481. 

spasmodic,  478.. 


Cough,  whooping,  482. 
Cretinism,  515. 
Cricoid  cartilage,  47. 
Crico-thyroid  muscle,  61. 
Croup,  895. 

after  tracheotomy,  406. 
differential  diagnosis  of,  from  abscess.of 
the  phar3'nx,  156. 
Cryptogamic  origin  of  diphtheria,  97. 
influenza,  262. 
Cubebs  in  croup,  405. 

oleo-resin  of,  in  ozasna,  272. 
Cuneiform  cartilages,  48. 
Cynanches,  78. 
Cystic  tumors  of  the  thyro-hyoid  bursse,  513, 

tonsils,  125. 
Czermak,  as  an  exponent  of  larj-ngoscopy,  11. 
his  method  of  auto-laryngoscopy,  37. 
Deafness  in  measles,  107. 
Degenerations  of  the  thymus  gland,  531. 
thyroid  gland,  518. 
Deglutition  in  abscess  of  the  pharjmx,  153. 

chronic  follicular  pharyngitis,  165. 
diphtheria,  99. 
scarlatina,  109. 
Demon stro-laryngoscopy,  40. 
Deodorizing  agents  for  use  with  nasal  douche, 

281. 
Depression  of  the  epiglottis,  25,  385. 
Deviations  of  the  septum  of  the  nose,  301. 
Diaphoresis  in  the  treatment  of  coryza,  256. 
Differentiation   of    diphtheria,  from   affections 

simulating  it,  100. 
Dilatation  of  the  oesophagus,  222. 
Dilator,  for  facilitating  the  entrance  of  the  tra- 
cheotomy-tube, 503. 
Distensible  tissue  of  the  nasal   nuicous  mem- 
brane, 244. 
Diseases  of  the  throat,  in  general,  1. 
Diverticulum  of  the  oesophagus.  195. 

l^harj'ux,  195. 
Douche,  the  laryngeal,  387. 

nasal,  278. 
Dysphonia,  from  ligation  of  the  carotid,  460. 
Bar-cough,  481. 
Ear,  disease  of  middle,  from  use  of  nasal  douche, 

289. 
Ecraseur,   adaptation  of,   for  removal  of  naso- 
pliar3'ngeal  tumors,  207. 
for  removal  of  tonsils,  131. 

laryngeal  tumors,  441. 
Elastic  membrane  of  the  larynx,  48. 
Electricity  in  anosmia,  290. 
aphonia,  471. 

glosso-pharyngeal  paralysis,  225. 
goitre,  525. 

paralysis  of  the  pharjaix  and  oeso- 
phagus, 224. 
spasm  of  the  oesophagus,  222. 


INDEX. 


5-77 


Electricity  in  spasmodic  congh,  480. 

sufEocative  larj-ngismus,  477. 
Electrodes,  laiyngoal,  471. 
Electrolj-sis  in  enlarged  tonsils,  1.32. 

naso-pharyngeal  tumors,  207. 
Elephantiasis  of  the  larynx,  390. 
Elongation  of  the  uvula,  25,  145. 

simulating      consump- 
tion, 169. 
Elsberg's  nostril  dilator,  75. 
Emetics  in  croup,  402. 
Emphysema  from  whooping-cough,  484. 
Euchondroma  of  the  palate,  140. 

pharynx.  104. 
Enlarged  tonsils,  24,  126. 
Epiglottis,  47. 

appearance  of  the,  iu  the  laryngo- 

scopic  image,  51. 
-holders,  20. 
large,  a  cause  of  spasmodic  cough, 

479. 
management   of    the,    in   laryngo- 
scopj',  25. 
Epistaxis,  245. 

in  measles,  106. 
Epithelium,  destruction  of,  in  inflammations  of 
mucous  membranes,  3. 
of  the  laryngeal  mucous  membrane, 
64. 
Erysipelatous  sore  tliroat,  110. 
Erythematous  sore  throat,  79. 
Eustachian    tube,    appearance    of    pharyngeal 
orifice  of,  in  a  case  of  cleft 
palate,  186. 
pharyngeal  orifice  of  the,  74. 
Examination  of  tlie  throat,  6. 

one's  o^Ti  larynx,  35. 

the  laryngeal  image,  in  detail, 

50. 
nasal  passages,  anteriorly,  75. 
naso-pharyngeal  region,  68. 
nostrils,  OS. 
posterior  nares,  68. 
through  a  wound  in  the  larynx  or  tra- 
chea, 43. 
Exanthemata,  sore  throats  of  the,  104. 
Excision  of  the  cBsophagus,  220. 
tonsUs,  128. 
uvula,  145. 
Excrescences  in  the  laiynx  following  croup,  404. 
measles,  107. 
in  syphilis,  116. 
on  the  uvula,  147. 
Exhibition  of  a  patient's  laryiix  to  others,  40. 
Exophthalmic  goitre,  515. 
Exostoses  of  the  frontal  sinuses,  331. 

pharyngeal  vertebrae,  194. 
External  manipulation  of  the  larynx  as  a  cure  in 
aphonia,  474. 


Extirpation  of  tumors  in  the  neck,  510. 
Extraction  of  foreign  bodies  from  the  larynx,  455. 
nostrils,  303. 
(Esophagus,  234. 
Exudation  of  diphtheria,  98. 
measles,  107. 
scarlatina,  108. 
False  croup,  396. 

vocal  cords,  49. 
Falsetto  tones,  67. 
Fancied  bodies  in  the  pharynx  and  ossophagus, 

239. 
Fatty  tumor  of  the  oesophagus,  228. 
Fibrin,  in  secretions  from  diseased  mucoiis  mem- 
brane, 3. 
Fibrous  gi-owths,  thickened  membrane  of  chronic 
coryza  mistaken  for,  263. 

tumor  of  the  oesophagus,  228. 
Filtrum  ventriculi,  61. 
Fistule  of  the  larynx  and  trachea,  395. 
oesophagus,  214. 
oesophageal,  231. 
tracheo-cesophageal,  238. 
Flap  amputation  of  the  uvula,  143. 
Follicular  pharyngitis,  156. 
Forceps-holder  for  nitrate  of  silver,  422. 
laryngeal,  428. 
oesophageal,  2.35. 
Forcible  elevation  of  the  epiglottis,  386. 
Foreign  bodies  in  the  larynx  removed  under 

laryngoscopy,  455. 
Foreign  bodies  in  the  nostrils,  301. 

oesophagus,  232. 
tonsils,  125. 
Fovea  centralis,  57. 
Fractures  of  the  larynx,  487. 

trachea,  493. 
Frog-face,  196. 

Frontal  sinuses,  affections  of  the,  325. 
Fungus  of  whooping-cough,  483. 
Garcia's  observations  in  auto-laryngoscopy,  11. 
Galvano-cautery,  accidental  wound  of  pharynx 
caused  by,  211. 

laryngeal  instruments  for,  442. 
in  enlarged  tousUs,  132. 
nasal  tumors,  313. 
naso-pharyngeal  tumors,  207. 
Gland,  afEections  of  the  thymus,  529. 
thyroid,  514. 
Glands  of  the  larynx,  64. 
Glandular  enlargements  in  abscess  of  the  pha- 

rjmx,  153. 
Glandular  enlargements  in  scarlatina,  110. 

hj-pertropliy  at  vault  of  pharynx,  174 
tissue  at  vault  of  pharynx,  as  seen  m 

a  case  of  cleft-palate,  184. 
vegetations  at  vault  of  pharynx,  190. 
Glosso  epiglottic  folds,  51. 

fossse  or  sinuses,  52. 


5  78 


INDEX. 


G-losso-epiglottic  ligament,  51. 
G-losso-pharyngeal  paralysis,  225. 
Glottis,  56. 

muscular  forces  producing  changes  in 
the  fomi  of  the,  60. 
Glj'cerine  in  ozcena,  275. 
G-oitre,  515. 
Gravedo,  251. 
Gross,  on  wounds  of  the  oesophagus,  2.31. 

pharynx,  210. 
Growths  in  the  larynx,  404. 

suitable  for  removal  with  forceps,  433. 
Hard-palate,  di-^dsion  of  the,  in  operations  for  the 

removal  of  nasopharyngeal  tumors,  200. 
Hay  asthma :  hay  fever,  258. 
Hearing,    impairment  of,  in  chronic  follicular 

pharyngitis,  167. 
Hemicrania,  due  to  nasal  calculi,  807. 
Hemorrhage  from  excision  of  the  tonsils,  130. 
Herpetic  eruption  of  membranous  sore  throat,  98. 
Hilton's  sac,  49,  55. 
Histology  of  the  larynx,  65. 
History  of  cesophagotomy,  241, 
Hot  and  cold  food,  as  a  cause  of  sore  throat,  '5. 
Hygroma  of  the  thyro-hyoid  bursae,  513. 
Hypertrophy,  glandular,  at  vault  of  pharynx,  174. 
of  the  thymus  gland,  580. 
thyroid  gland,  515. 
tonsils,  126. 
Hyijodermic  injections  in  aphonia,  473. 
H3T)ophosphites  in  diphtheria,  102, 
Hysterical  aphonia,  462. 
Idiosyncratic  coryza,  258. 
ozcena,  266. 
Illuminating  apparatus  for  laryngoscopy,  31. 

gas,    vapors    from,    in  whooping- 
cough,  485, 
Impediments  to  laryngoscopic  examination,  20. 
Infantile  coryza,  255. 
Infants,  syphilitic  sore  throat  of,  119. 
Infection  of  diphtheria,  97. 
Infiltration  of  the  sides  of  the  vomer,  297. 
Inflammation  of  the  trachea,  890. 

septum  narium,  296. 
Infra-glottic  laryngoscopy,  43. 
Influenza,  259. 
Inhaler,  nasal,  258. 
Inhalations  in  coryza,  257. 
croup,  401. 

spasmodic  cough,  480. 
whooping-cough,  485. 
Inhalation  of  irritant  siabstances  as  a  cause  of 

disease  of  the  throat,  5. 
Injections  in  epistaxis,  248. 

of  quinine  in  idiosyncratic  coryza,  259. 
Initial  disturbance,  points  of,  in  inflammations 

of  the  throat,  4. 
Inoculation  of  diphtheria,  98. 
Inspection  of  the  throat,  7. 


Instrumento-mania  of  larj-ngoscopists,  12. 
Introduction  of  the  laryngoscopic  mirror,  16. 
Iodide  of  potassium  in  goitre,  524. 
Iodine  inhalations  in  coryza,  257. 
Irritability  of  the  epiglottis,  885. 

fauces,  23. 
Irritation,  effect  of,  on  mucous  membrane,  2. 
Johnson's  method  of  auto-laryngoscopy,  .38. 
Knives,  laryngeal,  436. 
Laceration  of  the  oesophagus,  229. 

trachea,  494. 
Lactic  acid  in  croup,  404. 

Lamina  intermedia  of  the  th3Toid  cartilage,  66. 
Laryngeal  complications  iri  smaU-pox,  105. 

image,  examination  of  the,  in  detail, 

50.   • 
implications  in  sjqihilis,  116. 
muscles,  61. 

oedema  of  chronic  laryngitis,  345. 
ravages  in  phthisis,  862. 
sac,  49. 
Laryngitis  acute,  333. 

chronic,  347. 
cedematous,  3S7. 
Laryngismus  stridulus,  475. 
Laryngo-pharyngeal  fossa,  siniis  or  sulcus,  48. 

afEections  of  the,  505. 
Laryngoscope,  the,  11. 

Laryngoscopic  appearances  in  diphtheria.  99. 
smaU-pox,  105. 
mirror,  13. 

introduction  of  the,  16. 
position  of  the,  17. 
Laryngoscopy,  10. 
Laryiigo-tracheotomy,  497. 
Laryngotomy,  500. 
Larj'ngotomy.  sub-hyoidean,  419. 
Larynx,  affections  of  the,  S33. 

artificial  openings  into  the,  496. 
catheterization  of  the,  505. 
contusions  of  the,  495. 
examination  of  one's  own,  35.    . 
fistvile  of  the,  895. 
foreign  bodies  ui  the,  454. 
fractures  of  the,  487. 
growths  in  the,  406. 
oedema  of  the,  887. 
regional  anatomy  of  the,  47. 
wounds  of  the,  486. 
Lateral  crico-arj-tenoid  muscle,  61. 
Le\\'in's  method  of  generating  nascent  vapors  of 

muriate  of  ammonia,  276. 
Lime,  vapor  of,  by  mhalation  in  croup,  401. 
Lingual  sinuses,  52. 
Liquor  ammonia  in  croup,  405. 
Local  applications  in  ozoena,  273. 
London  paste  in  enlarged  tonsils,  131. 
Mackenzie's  laryngeal  electrodes,  471. 
JIaculaj  flavffi,  57. 


IXEEX. 


579 


ilalformation  of  the  cesophagu?,  912. 
Malignant  gro^^-ths  in  the  nasal  fossfe,  315. 

scarlatina,  109. 
Management  of  respiration  in  laryngoscopj-,  2". 
Management  of  the  tongue  in  laryngoscopy,  21. 
Manipulations  VN-ithin  the  larynx,  SSO. 
Measles,  sore  throat  of,  106. 
Mechanical  treatment  of  epistaxis,  248. 
Medicinal  solutions  applicable  for  use  by  the 

nasal  douche,  283. 
Membrane,   formed  in  diseases  of  the  mucous 

membrane,  4. 
Membranous  coryza,  352. 

growths  ill  the  larynx,  414. 
sore  throat,  92. 
Jletz'  nostril  dilators,  76. 
Jlicroscopic  apisearances  of  adenoid  vegetations 

at  the  vault  of  the  phar3'nx,  191. 
Mirror,  the  laryngoscopic,  13. 
Moisture  in  diphtheria,  101. 
Molten  nitrate  of  silver,  421. 
Mortality  of  pharyngeal  abscess,  150. 
Mouth  distenders,  142. 
Mucous  membrane,  normal  secretion  of,  2. 
effect  of  imtation  of,  2. 
pellicle  or  membrane  formed 

in  diseases  of,  4. 
varying  adherence  of,  in  dif- 
ferent portions  of  the  la- 
rynx, 64. 
Mucous  tubercle,  118. 
Mucus,  formation  of,  3. 
Muniijs,  512. 

Muriate  of  ammonia  in  the  nascent  state,  2~6. 
Muscle  arj  teno  epiglottic,  56,  62. 
arytenoid,  61. 
cephalo-pharyngeal,  179. 
compressor  sacculi  laryngis,  56,  62. 
crico-ai7tenoid,  lateral,  61. 

posterior,  60. 
crico- thyroid,  61. 
pharyngo-palatine,  133. 
thyro-ai-3'tenoid,  62. 
thyro-epiglottic,  62. 
triceps-laryngea  (Bataille),  63. 
Mycelium  in  a  case  of  infiltration  at  the  sides  of 

the  vomer,  299. 
Kasal  abscess,  250. 
calcuU,  303. 
catarrh,  263. 
discharges,  from  presence  of  foreign  bodies, 

302. 
douche,  278. 

serious  disease  of  middle  ear  from 
use  of,  289. 
inhaler,  258. 
mucous  membrane,  243. 

thickening  of,  in  chro- 
nic coryza,  264. 


Nasal  passages,  affections  of  the,  243. 

calcareous  accretions  in  the,  805. 
syphilitic  affections  of  the,  292. 
tumors  in  the,  307. 
polyps,  307. 
Nascent  fumes  of  muriate  of  ammonia,  276. 
Naso-pharj-ngeal  structures,  examination  of  the, 

68. 
Naso-pharyngeal  tumors,  196. 
Nebulizers,  laryngeal,  388. 
Neck,  affections  of  the  tissues  of  the,  507. 
Nerves  of  the  larynx,  65. 
Ner^^ous  shock  in  burns  and  scalds  of  the  throat, 

12:1 
Neudorfer,  on  infi-a-glottic  laryngoscopy,  43. 
Neurilemmatous  tumor  in  the  nostril,  314. 
Nitrate  of  silver  in  chronic  pharyngitis,  171. 
croup,  403. 
diphtheria,  101. 
laryngeal  growths,  424. 
whooping-cough,  486. 
Nosti-il-dUators,  75. 

Nostrils,  attention  to  condition  of,  in  diphtheria, 
102. 
foreign  bodies  in  the,  301. 
occlusion  of  the,  294. 
paralysis  of  the,  293. 

Occlusion  of  the  nostrils,  294. 

oesophagus,  212. 
posterior  nares,  295. 
Oedema  of  the  larynx,  337. 

differential  diagnosis  of, 
from  abscess  of  the  pharynx,  156. 
in  bums  and  scalds,  123. 
ei-ysipelas,  110. 
small-pox,  104. 
of  the  uvula,  146. 
Oesophageal  bougies,  -219. 
forceps,  2S5. 
horse-hair  snare,  236. 
QEsophagitis,  212. 
a?sophagoscopy,  46. 
(Esophagotomy,  220,  240. 
Gilsophagus,  auscultation  of  the,  217. 

congenital  fistule  of  the,  214. 

occlusion  of  the,  212. 
constriction  of  the,  221. 
dilatation  of  the,  216,  222. 
division  of  the,  219. 
excision  of  the,  220. 
fancied  bodies  in  the,  239. 
foreign  bodies  in  the,  232. 
paralysis  of  the,  224. 
rupture  of  the,  230. 
spasm  of  the,  221. 
special  aifections  of  the,  212. 
stricture  of  the,  215. 
tumors  of  the,  227. 


5  so 


INDEX. 


CEsophagup,  ■wounds  of  the,  229. 
Ointments,   applications  of,   to  the  nasal  pas- 
sages, 274. 
Olfaction.  243. 
Operations  for  goitre,  598. 
Opium  in  nasal  pol}-ps,  311. 
Origin  of  lar_vngeal  growths,  412. 
Osseous  tumors  of  the  nasal  fossffi,  317. 

pharynx,  194. 
Otoirlioea  following  scarlatina,  108. 
Over-feeding,  lari-ngitis  from,  .353. 
Oxygen  in  croup,  405. 
OzKna,  265. 

Palate,  adhesions  of  the,  to  adjacent  parts,  14. 
cleft  of  the,  141. 
paralysis  of  the,  144. 
special  affections  of  the,  133. 
tumors  of  the,  137. 
PaijiUoma  of  the  pharynx,  195. 
Paralytic  aphonia,  465. 
Paralysis,  glosso-pharyngeal,  225. 
of  diphtheria,  100. 
the  nostrils,  293. 
oesophagus,  224. 
palate,  144 

in  sypliilis,  114. 
pharynx,  224. 
vocal  cords,  467. 
Parasites  in  the  oesophagus,  232.  - 
Parotitis,  512.  ■ 
Pertussis,  482. 
Phagedenic  sore  throat,  95. 
Pharyngeal  bursa,  179,  181,  187. 
erysipelas.  111. 
tonsil,  187. 
Pharyngitis,  acute,  82. 

chronic,  156. 
sicca,  169. 
Pharyngocele,  195. 
Pharyngo- palatine  muscles,  133. 
Pharyngotomy,  subhyoidean,  450. 
Pharj'nx,  abscess  of  the,  148. 

appearance  of  glandular  tissue  of,  in 

a  case  of  cleft-palate,  185. 
enchondroma  of,  194. 
exostosis  of  vertebral  wall  of,  194. 
extension  of  inflammation  of  the,  to 

the  respiratory  passages,  4. 
fancied  bodies  in  the,  239. 
glandiilar  hypertrophy  at  vault  of,  174. 
osseous  tumors  of  the,  194. 
Pharynx,  papilloma  of  the,  195.      . 
paralysis  of  the,  224. 
participation  of  the,  in  diseases  of  the 

digestive  apparatus,  4. 

tumors  of  the,  193. 

wounds  of  the,  209. 

Phlegmonous  sore  throat,  82. 

Phonation,  physiology  of,  403. 


Phthisis,  laryngeal  growths  in,  411 

the  chronic  laryngitis  of,  355. 

Physiological    movements    made    available    in 
laryngoscopic  manipulations,  59. 

Piltz,  the,  of  whooping-cough,  483. 

Platinum  bulbs  for  applications  of  caustics,  420. 

Pneumatocele,  395. 

Polyps  of  the  nostrik,  " 
oesoplif- , 

Position  of  the  laryu-  liiTor,  17. 

Posterior  crico-arytenu-..  i^iuscie,  60. 

nares,  congenital  occlusion  of  the,  295. 
examination  of  the,  68. 

Powder  insufflators,  laryngeal,  SS9. 

Powders  by  insufflation  in  ozajna,  215. 

Pregnancy,  goitre  of,  519. 

Probe,  roughened  for  nitrate  of  silver,  422. 

Processus  vocalis,  57. 

Pseudomembranous  croup,  396. 

Pseudo-plasm  in  membranous  sore  throat,  94. 

Purulent  croup,  396. 

Pyramidal  sinuses,  48. 

Pyrifonn  sinuses,  48. 

Quadrangular  membrane  of  the  larynx,  48. 

Quinine,  hydrochlorate  of,  in  whooping-cough, 
485. 
injection  of,  in  coryza,  259. 

Quinsy,  82. 

Keci]5ro-lar5-ngoscopy,  40. 

Reflex  irritation  productive  of  coryza,  265. 

Regional  anatomy  of  the  larynx,  47. 

Relative  relations  of  the  larynx  and  its  image  in 

the  laryngoscopic  mirror,  19. 
Removal  of  the  entire  larynx,  450. 

foreign  bodies  from  the  oesophagus, 

2.35. 
nasal  polyps,  .311. 
Respiration  in  abscess  of  the  pharynx,  153. 
scarlatina,  109. 
management    of    the,   in    laryngo- 
scopy, 27. 
Retro-pharyngeal  abscess,  148. 
-oesophageal  abscess,  154. 
Rhinitis,  251. 
Rhinoliths,  305. 

from  foreign  bodies,  303. 
Rhinorrhcea,  251. 
Rhinoscopic  image,  251. 
Rhinoscopy,  C8. 
Rima  glottidis,  56. 

Rinsing,  fluids  for,  with  nasal  doxiche,  280. 
Rumination,  195,  210,  222. 
Rui^ture  of  the  oesophagus,  230. 

swellings  in  oedema  of  the  lar- 

}-nx,  344. 
trachea,  494. 
Salivation  in  small-pox,  105.. 
Santorini,  cartilages  of,  47. 


INDEX. 


5S1 


Scalds  and  bums  of  the  throat,  1'28. 
Scarification  in  oedema  of  the  larj-nx,  343. 
Scarlatina,  the  sore  throat  of,  107. 
Scissors,  laryngeal,  438. 

use  of,  in  removal  of  laryngeal  gro'wths, 
435. 
Scrofulous  ozfena,  268. 
Searching  for  foreign  bodies  in  the  air-passages, 

460. 
Secretions  of  coryza,  253. 

the  normal,  of  mucous  membrane,  2. 
Semeleder,  on  auto-infra-glottic  laryngoscopy, 

45. 
Semeleder,  on  oesophagoscopy,  46. 
Sesamoid  cartilages,  47. 
Septum,  bronchia],  457. 

narlum,  deviations  of  the,  801. 

inflammation  of  the,  296. 
tumors  of  the,  300. 
Sinuses,  affections  of  the  pharyngo-pharyngeal, 

505. 
Sma!l-pox,  the  sore  throat  of,  104. 
Smell,  acuteness  of,  291. 

loss  of,  289. 
Smyly's  method  of  demonstrative  laryngoscopy, 

43. 
Snares  for  removal  of  laryngeal  growths,  439. 

oesophageal,  236. 
Soft  palate,  division  of,  in   operations  for  re- 
moval of  naso-pharyngeal  tumors,  199. 
Sore  throat,  78. 

from  bums  and  scalds,  12.3. 
of  erj'sipelas.  110. 
of  measles.  106. 
scarlatina,  107. 
small-pox,  104. 
sj'philis,  113. 
the  exanthemata,'  104. 
Spasm  of  the  glottis  m  croup,  397. 
(Esophagus,  221. 
trachea,  477. 
Spasmodic  cough,  473. 
croup,  396. 
Speech,  in  glandular  hypertrophy  at  vault  of 

pharynx,  174. 
Sponge  holders,  laryngeal,  386,  421. 

probang,  use  of,  in  croup.  403. 
Sprays,  use  of,  in  chronic  pharj-ngitis,  173. 
scarlatina,  110. 
syphilitic  sore  throat,  119. 
Spray- pi'oducers,  388. 
Stenosis  of  the  larynx  from  burns  and  scalds, 

124. 
Stimulation  in  croup,  403. 
-Stricture  of  the  oesophagus,  215. 

from      biurns     and 
scalds,  124. 
»  following  phlegmon- 

bus  sore  throat,  82. 


Stnictirres  subjected  to  rhinoscopic  inspection.  71 
Strychnia,  use  of  in  aphonia,  473. 
Sulcutxneous  fistule  of  lai-ynx  and  trachea,  395. 
Siab-glottic  oedema  of  the  larynx,  342. 
Sub-hyoidean  laryngotomj',  419,  497. 
Submucous  infiltration  at  sides  of  vomer,  297. 
Suffocative  laryngismus.  475. 
Suicidal  wounds  of  the  pharynx,  210. 
Sulphur  in  diphtheria,  101. 
Sulphuric  ether  in  croup,  404. 
Sunsti-oke,  paralysis  of  pharj-nx  following,  224. 
Supra-thjToid  larj^ngotomj^  450. 
SyphUis,  chronic  laryngitis  of,  .;67. 
laryngeal  growths  in,  411. 
simulating  epithelioma,  117. 
the  state  of  the  thymus  in,  532. 
Syphilitic  affections  of  the  nasal  passages,  292. 
laryngitis,  116. 
ozcena,  270. 
sore  throat,  113. 

in  infants,  119. 
warts  in  the  larynx,  116. 
Syphon  nasal  douche,  287. 
SjTinge,  laryngeal,  387. 
Systemic^ poisoning  of  diphtheria.  99. 
Tampon  for  the  posterior  nares,  250. 
Tamponing  in  epistaxis,  249. 

the  posterior  nasal  fossa  in  opera- 
tions in  this  region,  323. 
Tannin,  in  the  treatment  of  nasal  polyps,  311. 
Throat,  diseases  of  the,  in  general,  1. 

examination  of  the,  6. 
Thudichum's  nasal  douche,  279. 
nostril  dilators,  76. 
ThjTnitis,  529.- 

Thymus  gland,  affections  of  the,  529. 
Thyroid  cartilage,  lamina  intermedia  of  the,  66. 

gland,  affections  of  the,  514. 
Thyro-aiytenoid  muscle,  62, 
Thyro-epiglottic  muscle,  62. 
Thyro-pharyngo-palatine  muscle,  134. 
Thyrotomy, -445,  497. 

Tobold's  illuminating  apparatus  for  laryngosco- 
py. 31,  35. 
Tobold's  perforated  canule,  and  mirror  for  in- 
fra-glottic laryngoscopy,  44. 
Tolerance  of  growth  in  the  larynx,  418. 

of  manipulations  ■within  the  larynx, 
385. 
Tongue-depressox's,  7. 
Tonsil,  the  pharyngeal,  187. 
Tonsillitis,  82. 

maligna,  82. 
TonsiUotomes,  129. 

Tonsils,  chronic  hypertrophj-  of  the,  1C6. 
special  affections  of  the,  125. 
the,  in  syphilis,  114. 
Trachea,  affections  of  the,  333. 

artificial  openings  into  the,  496. 


583 


lA^DEX. 


Trachea,  catheterization  of  the,  505. 
constriction  of  the,  393. 
contusions  of  the,  495. 
fistule  of  the,  395. 
foreign  bodies  in  the,  454. 
fractures  of  the,  493. 
inflammation  of  the,  390. 
laceration  of  the,  494. 
local  applications  to  the,  392. 
rupture  of  the,  494. 
spasm  of  the,  'i77. 
tumors  of  the,  453. 
wounds  of  the,  486. 
Tracheal  implications  in  syphilis,  116. 
Tracheitis,  treatment  of  chronic,  392. 
Tracheo-oesophageal  fistule,  2.33. 
Tracheoscopy,  43. 
Tracheotome,  504. 
Tracheotomy,  500. 

in  croup,  403. 
diphtheria,  103. 
laryngeal  gro\vths,  449. 
oedema  of  the  larynx,  344. 
tubes,  498. 
Transit  of   foreign  bodies  after  having    been 

swallowed,  238. 
Traumatic  fistule  of  the  larynx  and  trachea,  395. 
Treatment  of  aphonia,  470. 

chronic  laryngitis,  372. 

croup,  400. 

foreign  bodies  in  the  air  passage, 

459. 
gro^rths  in  the  larynx,  417. 
Tubage  of  the  larynx  and  ti-achea,  505. 
Tuberculous  degeneration  beginning  in  the  lin- 
gual sinuses,  52. 
Tuberculous  degeneration  beginning  in  the  pos- 
terior wall  of  the  larynx,  55. 
Tuberculous  laryngitis,  364. 

sore-throat,  160. 
Tumors,  burs.il,  of  thyro-hj-oid  region,  513. 
cancerous,  of  the  tonsils,  125. 
cystic,  of  the  tonsils,  125. 
naso-pharyngeal,  196. 
of  tlie  frontal  sinuses,  327. 
larjTix,  41.3. 
neck,  509. 
nasal  passages,  307. 

septum,  300. 
oesophagus,  227. 


Tumors  of  the  palate,  137. 

pharj'nx,  193. 
trachea,  452. 
Tiirck,  as  an  exponent  of  laryngoscopy,  11. 
Turbinated  bones,  mucous  membrane  over.  243. 
Ulcerated  sore-throat,  89. 
Ulceration  of  the  trachea,  393. 
Ulcerative  ravages  in  syijhUis,  115. 
Unilateral  aphonia,  405. 
Upjier  maxillary  bone,  removal  of,  in  operations 

on  naso-pharyngeal  tumors,  200. 
Use  of  the  nasal  douche,  282. 
U^T-ila,  special  affections  of  the,  145. 
Uvulatome,  145. 
Valleculaj,  52. 
Vapors  of  lime  in  croup,  401. 

in  ozEena,  2V5. 
Vault  of   pharynx,  glandular  hypertroiJhy  at, 

174 
Vegetations,  glandular,  at  vault  of  pharynx,  190. 
Veins  of  the  larynx,  65. 
Ventricles  of  the  larynx,  49. 
Ventricular  bands,  49. 

Verneuil's  case  of  naso-pharyngeal  polyp,  201. 
Vocal  cords,  49.    , 

their  appearance  in  the  laryngosco- 
pic  image,  56. 
Vocal  cords,  duplicatures  of  the  elastic  mem- 

■  branes  of  the  larynx,  67. 
Vocal  cords,  Mstology  of  the,  67. 
muscle,  the,  63. 
processes,  57. 
Voice,  after  croup,  406. 

factors  of  the,  462. 
in  abscess  of  the  pharynx,  153. 
in  chronic  follicular  pharjugitis,  164 
Vomer,  submucous  infiltration  at  the  sides  of 

the,  297. 
Warmth  and  moisture  m  the  treatment  of  croup. 

400. 
Water-bag,  in  epistaxis,  248. 
Whooping  cough,  482. 
Wire  snares,  439. 

Wiutrich's  method  of  indirect  examination  of 
the  condition  of  the  nasal  passages,  by  per- 
cussion, 77. 
Wounds  of  the  larynx  and  trachea,  486. 
oesophagus,  229. 
pharynx,  209. 
Wrisberg,  cartilages  of,  54,  66. 


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